An Attachment Perspective on Therapeutic Processes and Outcomes

An Analysis of the Longitudinal Effects of Academic Stress, Insecure Attachment, and Sense of Community on Adolescent Suicidal Ideation

This study aimed to examine the independent influences of academic stress, insecure attachment, and sense of community on suicidal ideation among adolescents. In particular, the independent influence of the sense of community on adolescent suicide was verified by controlling for other variables. For this purpose, youth data (7324 persons) from the panel data of the 4th to 6th Korean Education Longitudinal Studies of the Korea Educational Development Institute were used. Statistical analyses were performed using a generalized estimation equation (GEE). The analysis revealed that gender, academic stress, insecure attachment, and sense of community significantly influenced suicidal ideation. Female students had higher suicidal ideation than male students, and the higher the academic stress and degree of insecure attachment, the higher the suicidal ideation. In particular, the independent influence of a sense of community on suicidal ideation was significant; the higher the sense of community, the lower the suicide ideation score. The implication of this study is to comprehensively consider the factors related to adolescent suicidal ideation in various systems based on Bronfenbrenner's ecological theory. This research suggests that helping schools and communities to increase their sense of community, which is a macrosystem factor, is important in preventing adolescent suicide.

How secure is the secure base? Romantic attachment, emotion regulation, and psychotherapists' role as secure base figures

In 1988, Bowlby posited that the emotional availability of psychotherapists in establishing a secure base environment is influenced by their personal relational history. Despite the acknowledged influence of the therapist's attachment on therapeutic processes and outcomes, the therapist's role as a secure base figure has received insufficient attention. This study delves into the connection between psychotherapists' attachment organization and their self-perceived roles as secure base figures within clinical contexts. Additionally, we explore the mediating role of emotion regulation processes in this context. The dataset comprises self-reports from 384 psychotherapists with diverse theoretical orientations. Our analysis reveals both direct and indirect effects of psychotherapists' attachment on the provision of a secure base. Emotion regulation, specifically through the dimension of clarity, emerges as a significant mediator in this relationship. This study offers a distinctive contribution to deepening our understanding of the relational dynamics inherent to psychotherapeutic practice. It sheds light on the nuanced relation between attachment and emotion regulation, influencing the psychotherapist's role as a secure base figure in psychotherapy. The discussion of the results additionally emphasizes key implications for clinical practice and therapists' training.

Group member attachment style interacts with actor and partner helping alliance to predict decreasing binge eating episodes

OBJECTIVE

An individual's attachment style may impact how they interact with their therapy group. This study examined the moderating role of a group member's attachment on the dynamic relationships between that group member's (actor) and other group members' (partner) therapeutic alliances and symptom outcomes. Method: This is a secondary analysis of data from a trial testing the outcome of emotionally-focused group therapy for binge-eating disorder. The sample consisted of 2,360 sessions nested within 118 group members who attended a 20-session treatment. Patients recorded binge eating episodes (BEE), their body weight and an alliance measure session-by-session.

RESULTS

Dynamic structural equation modelling showed decreases in BEE and weight over the therapy. When attachment style was not included in the model, higher-than-average partner's alliance scores in the previous session were related to decreases in BEE in the current session. Attachment style moderated these actor and partner effects. For patients with preoccupied attachments, higher-than-average actor alliance in the previous session was related to subsequent decreases in BEE. For patients with dismissing or disorganized attachments, higher partner alliance in the previous session was related to subsequent decreases in BEE.

CONCLUSION

Group members' attachment characteristics can play a role in the development of alliance-outcome patterns in group therapy.

Adverse childhood experience and young adult's problematic Internet use: The role of hostility and loneliness

BACKGROUND

Few studies have explored the relationship between adverse childhood experiences (ACEs) and problematic Internet use (PIU) during young adulthood. Moreover, even fewer studies have explored the roles of loneliness (social and emotional) and hostility in this relationship.

METHODS

This study used data from the Taiwan Youth Project (2011-2017). The analytical sample included 1885 participants (mean age = 31.3 years). PIU was measured using the short form of Chen's Internet Addiction Scale (2017). ACEs were assessed at the baseline of the adolescent phase (mean age = 14.3 years); this indicator has undergone recent revision. Hostility (three items from the Symptom Checklist-90-Revised) and loneliness (six items from the De Jong Gierveld scale) were measured in 2011 and 2014, respectively.

RESULTS

ACEs were associated with hostility and loneliness (emotional and social). Additionally, hostility (β = 0.62, p < .01) and emotional loneliness (β = 0.44, p < .01) were significantly associated with PIU. Most mediating paths (e.g., ACE → hostility → PIU) were significant, based on the bootstrapping results.

CONCLUSIONS

This study suggests that ACEs have a long-term shadow effect on PIU in young adults. ACEs show an indirect association with PIU through both hostility and loneliness, as well as involving the relationship between them.

Between- and within-person effects of affective experiences on coping in CBT: Direct effects and interplay with therapeutic alliance and resource activation

OBJECTIVE

The role of affective experiences (AE) in cognitive-behavioral therapy (CBT) has rarely been investigated. We examined between- and within-person effects of AE on coping in CBT for family caregivers and interactions with therapeutic alliance and resource activation.

METHODS

67 family caregivers rated AE, therapeutic alliance, resource activation, and coping after each of 12 sessions of telephone-based CBT. We examined direct session-to-session effects of AE on coping in structural equation modeling and interactions of AE with therapeutic alliance and resource activation in multilevel models.

RESULTS

AE did not directly predict coping. Instead, within-person effects of AE interacted with simultaneous within-person emotional bond. Given strong emotional bond, AE positively predicted coping, whereas given weak emotional bond, AE negatively predicted coping. Further, cross-level interactions of between-person AE and within-person agreement on collaboration and resource activation indicated that these positively predicted coping only in dyads with high between-person AE.

CONCLUSION

AE may enhance coping when complemented with strong emotional bond. Further, within-person effects of agreement on collaboration and resource activation seem to rely on a certain degree of between-person AE. Results are discussed in relation to current findings on emotional processing in CBT.

Therapists' oxytocin response mediates the association between patients' negative emotions and psychotherapy outcomes

BACKGROUND

Existing literature suggests that patients' experiences of emotions, especially negative emotions, predict outcomes in psychotherapies for major depressive disorder. However, the specific mechanisms underlying this effect remain unclear. Based on studies pointing to the role of oxytocin (OT) in attachment relationships, we proposed and tested a mediation model where the therapists' hormonal responses, as represented by increases in their OT levels, mediates the association between negative emotions and symptomatic change.

METHOD

OT saliva samples (pre- and post-session, N = 435) were collected on a fixed schedule over 16 sessions from the therapists of 62 patients receiving psychotherapy for major depression. The Hamilton Rating Scale for Depression was administered to the patients before the sessions, and the patients reported their in-session emotions after the sessions.

RESULTS

The findings support the proposed within-person mediation model: (a) higher levels of negative emotions in patients predicted greater increases in therapist OT levels pre- to post-session throughout treatment; (b) greater OT levels in therapists, in turn, predicted reduction in patients' depressive symptoms on the subsequent assessment; and (c) the therapists' OT levels significantly mediated the association between patients' negative emotions and reduction in their depressive symptoms.

LIMITATIONS

This design precluded establishing a time sequence between patients' negative emotions and therapists' OT; thus, causality could not be inferred.

CONCLUSION

These findings point to a possible biological mechanism underlying the effects of patients' experiences of negative emotions on treatment outcomes. The findings suggest that therapists' OT responses could potentially serve as a biomarker of an effective therapeutic processes.

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.

"INTEGRO INTEGRated Psychotherapeutic InterventiOn" on the Management of Chronic Pain in Patients with Fibromyalgia: The Role of the Therapeutic Relationship

Fibromyalgia (FM) is a chronic disease characterized by a heterogeneous set of physical and psychological conditions. The chronic experience of disability felt by patients and the impact on quality of life (QoL) of the disease may worsen the cognitive reappraisal ability and contribute to maintaining an altered pain modulation mechanism. This paper presents the study protocol of an INTEGRated psychotherapeutic interventiOn on the management of chronic pain in patients with fibromyalgia (INTEGRO). The aim of the study is to investigate the efficacy of an integrated psychotherapeutic intervention focused on pain management on QoL and pain perception, in a pilot sample of 45 FM patients with idiopathic chronic pain. The contribution of perceived therapeutic relationship (alliance) and physiological attunement, in both the patient and therapist, will be considered as possible mediators of intervention efficacy. Attachment dimensions, traumatic experiences, difficulties in emotion regulation, mindfulness attitude and psychophysiological profile will also be considered as covariates. The objectives are to evaluate longitudinally if patients will experience an increase in QoL perception (primary endpoint), pain-managing self-efficacy and emotion-regulation abilities as well as a reduction in pain intensity (secondary endpoints), considering the mediating role of perceived therapeutic alliance and physiological attunement in both the patient and therapist.

The association between attachment orientations and empathy: The mediation effect of self-concept clarity

Although earlier research had demonstrated significant links between attachment and self-concept clarity; attachment and empathy; and self-concept clarity and empathy respectively, there had been no studies examining these associations in conjunction with one another. Therefore, the present studies explored whether individual differences in self-concept clarity would mediate the relationship between attachment orientation (i.e., attachment anxiety and attachment avoidance) and empathy (i.e., empathic concern and personal distress). In Study 1, the association between attachment orientation and self-concept clarity was examined among 602 Hungarian university students. In Study 2, the relationship between attachment and empathy was investigated through self-concept clarity among 1000 Hungarian adults. The findings from both samples revealed that attachment avoidance and anxiety were negatively related to self-concept clarity. In Study 2, individuals with greater self-concept clarity showed greater empathic concern and lower personal distress. Attachment avoidance was associated with lower empathic concern, whereas there was no significant association with personal distress. Attachment anxiety was positively related to empathic concern and personal distress. Self-concept clarity partially mediated associations with attachment anxiety and aspects of empathy. These findings suggest the importance of attachment orientations in terms of their influence on the self with regard to interpersonal relations.

The Relevance of Internal Working Models of Self and Others for Equine-Assisted Psychodynamic Psychotherapy

Attachment characteristics play a key role in mental health and in understanding mental disorders. The aim of this study was to gain insight into the role the attachment characteristics can play in treatment effects in adult patients with intrapsychic and interpersonal problems who underwent Equine-assisted Short-term Psychodynamic Psychotherapy (ESTPP). In the first part of the study, we compared the effects of ESTPP to treatment-as-usual from a previous dataset regarding psychological dysfunction. For this, an explorative experimental non-randomized pre-treatment and 1-year post-treatment design was used. A mixed model revealed a significant decline in psychological dysfunction for both conditions, with no significant difference between the two. In the second part of the study, we examined the course of ESTPP effects over the period of 1 year when controlled for attachment styles and, subsequently, for internal working models of self and others. To this end, measurements were taken at baseline, 2 months waiting time, one-week intensive module, 6 months, and one year after the start of the treatment. Mixed models accounted for repeated measures showed significant improvements in psychological dysfunction, remoralization, and depression for ESTPP patients over time. The study implies that models of self and others may be used to predict the course of effects, which is relevant in determining what works for whom. In particularly, duration and intensity of therapy and a focus on the Model of Self seem relevant for shaping a more personalized treatment. ESTPP seems beneficial for patients with low pre-treatment attachment security.

Gender Differences in Attachment Anxiety and Avoidance and Their Association with Psychotherapy Use—Examining Students from a German University

Attachment anxiety and avoidance might explain gender differences in psychotherapy use, which is generally lower in men. In addition, university students are a particularly vulnerable group for mental health problems, and understanding psychotherapy use, especially among mentally distressed male students, is pivotal. A total of 4894 students completed an online survey answering questions regarding psychotherapy use and completing the PHQ-D identifying psychological syndromes. In addition, the ECR-RD12 was used to measure attachment anxiety and avoidance. Significant gender differences for attachment anxiety and avoidance emerged, showing higher attachment anxiety in female students and higher attachment avoidance in male students. Male students used psychotherapy significantly less than female students. Male students’ attachment anxiety and avoidance predicted psychotherapy use, while for female students, only attachment anxiety emerged as a significant predictor. Attachment anxiety is positively associated with psychotherapy use, and lower attachment anxiety in men may explain lower psychotherapy use in male students.

Illustrating systemic change in family therapy: How therapists' and clients' alliance perceptions codevelop over time

Research showing that caregivers', adolescents' and therapists' perceptions of the therapeutic alliance become more similar over time has not examined conceptual models, like emotional contagion and interdependence, that are theorized to account for this convergence. Objective: We modeled codevelopment in systemic family therapy to examine mutual influence and shared environment processes among the alliance perceptions of youth, caregivers, and therapists. Method: The self-report version of the System for Observing Family Therapy Alliances (SOFTA-s) was administered after sessions 3, 6 and 9-156 Spanish maltreating families and 20 therapists. Results: Using a triadic version of the repeated measures actor-partner interdependence analysis, a random intercepts cross-lagged panel model, we found significant effects of the shared environment and mutual influence in caregivers' and therapists' alliance scores over time, reflecting emotional contagion. Additionally, (i) therapists' alliance scores at session 6 significantly predicted youth alliance scores at session 9, and (ii) therapist alliance at session 6 significantly mediated the relationship between caregiver alliance at session 3 and youth alliance at session 9, suggesting that therapists bridge the caregiver's and youth's perceptions of the alliance. In successful (compared to unsuccessful) cases, therapists' alliance perceptions at session 6 positively influenced caregivers' alliance perceptions at session 9. Conclusion: Therapist's perceptions of the alliance can bridge differences in alliance perceptions of caregivers and adolescents resulting in greater similarity in alliance perceptions over time.

Predictors of posttraumatic stress symptom severity and meaning made in treatment-seeking veterans

OBJECTIVE

Combat-exposed veterans risk encountering events that disrupt beliefs. To facilitate reduced discrepancy between prior beliefs and current trauma appraisals, veterans may engage in a process of meaning-making. Meaning-making can lead to positive outcomes, such as integrating the traumatic event into one's life narrative or adapting global meaning (meaning made) or elicit distress. Given these potentially different outcomes, this study examined potential correlates of posttraumatic stress symptom (PTSS) severity and meaning made, including relationship attachment dimensions of anxiety and avoidance, and difficulties with emotion regulation, while controlling for combat exposure.

METHOD

Veterans receiving mental health services at a Veterans Affairs (VA) Medical Center and a VA community-based outpatient clinic (N = 130) completed measures through a paper-and-pencil survey. Almost all participants (92%) were male, with a mean age of 55.92 years.

RESULTS

In terms of meaning made, lower levels of attachment anxiety and emotional clarity (an aspect of emotion regulation) predicted higher meaning made. In terms of PTSS severity, higher attachment avoidance, attachment anxiety, and difficulties engaging in goal-directed behavior (an aspect of emotion regulation) significantly predicted higher PTSS severity.

CONCLUSION

Aspects of both attachment style and emotion regulation difficulties affect meaning made and PTSS severity. These constructs may be especially relevant for clinicians working with veterans to help PTSS and support meaning made postcombat.

Online group psychodynamic psychotherapy-The effectiveness and role of attachment-The results of a short study

The role of remote treatment, including psychotherapy, has increased during the COVID-19 pandemic. The results of research in this area are promising, initially pointing to similar effectiveness for online psychotherapy as that of face-to-face psychotherapy. A significantly smaller amount of research has been conducted on online group psychotherapy, in particular, in the psychodynamic paradigm. Many authors have drawn attention to the need to conduct further research, considering specific patient features, for example, personality traits, attachment style, age, and other demographic variables. This study conducted pre- and post-treatment (10 weeks) and a 6-week follow-up, on the effectiveness of online synchronous group psychodynamic psychotherapy (via Zoom) taking into account patients' attachment styles. Four main hypotheses were tested: H1: Patients will obtain a lower score in the attachment's dimensions of anxiety and avoidance; H2: Patients will get a lower level of symptoms and sense of loneliness; H3: Patients will have increased self-esteem; and H4: The anxiety and avoidance dimensions of the attachment will be predictors for the effectiveness of online psychodynamic group psychotherapy. Twenty-two outpatients participated in the study, out of which 18 suffered from neurotic, stress-related, and somatoform disorders (F40-F48), and four suffered from a depressive episode (F32.0, F32.1) according to ICD-10. The results of the pre-treatment test showed a reduction in the global severity of psychiatric symptoms (d = -0.526) and depressive symptoms (d = -0.5), as well as an increase in self-esteem (d = 0.444) and feelings of loneliness (d = 0.46). A change in the attachment dimension, anxiety (d = -0.557) and avoidance (d = -0.526), was also observed. The above results were maintained in the follow-up test conducted after 6 weeks. Additionally, a reduction in the symptoms of social phobia was observed. Attachment dimensions were not a predictor of the effectiveness of psychotherapy, but a decrease in avoidance during therapy was a predictor of increased symptoms of pain. The results of the research are promising in terms of psychiatric symptoms and increased self-esteem. During therapy, there may be a favorable change in attachment dimensions, but this variable was not shown to be a predictor of results. These results suggest that more controlled research is required.

Therapist Attachment and the Working Alliance: The Moderating Effect of Emotional Regulation

Objective: To explore whether the therapist's emotional regulation strategies moderate the relationship between therapist attachment and the working alliance from the therapist's perspective. Method: A non-experimental, descriptive correlational design was used. Sixty-three psychotherapists (6 men, 57 women) participated in this study, ranging in age from 27 to 69 years, with a mean age of 39.3 years. The therapists completed the Attachment evaluation questionnaire for adults, the Spanish Adaptation of the Working Alliance Inventory, and the Difficulties in Emotion Regulation Scale. Associations between attachment and emotional regulation traits and working alliance were examined using multilevel modeling, controlling for therapist demographics, and clinical experience. Results: Moderation analyses revealed significant interaction effects between therapist attachment and emotional regulation strategies. Conclusion: Attachment styles would not significantly affect the therapist's ability to establish an adequate therapeutic alliance bond. The results show that the attachment style of the therapists interacted with their emotional regulation abilities.

The Relationship Between Suicidal Ideation and Parental Attachment Among Adolescents: The Mediator of Anhedonia and Peer Attachment

Background: Previous studies had shown that poor quality of early parental attachment is a risk factor for suicide, but few have focus on the mechanism between suicidal ideation and parental attachment. The aim of this study was to explore how parental attachment, anhedonia, and peer attachment were associated with suicidal ideation in adolescents.

Method: Participants were enrolled in middle schools, in Hefei, Anhui, China. All participants completed socio-demographic characteristic and standard assessments on parental attachment, peer attachment, anhedonia, and suicidal ideation by paper surveys. The effect of parental attachment on suicidal ideation mediated by anhedonia and peer attachment was analyzed by a structural equation model (SEM) using SPSS AMOS 23.0.

Results: The SEM analysis revealed that the standard total effect of parental attachment on suicidal ideation was −0.137 (Z=−27.00, 95% confidence interval [CI; −0.147, −0.127], p<0.001), with a direct effect of parental attachment on suicidal ideation of −0.107 (Z=−21.40, 95% CI [−0.117, −0.098], p<0.001), while the indirect effects were−0.002 (Z=−3.33, 95% CI [−0.003, −0.002], p<0.001) in the pathway of parental attachment-anhedonia-peer attachment-suicidal ideation, −0.019 (Z=−19.00, 95%CI [−0.022, −0.017], p<0.001) in the pathway of parental attachment-anhedonia-suicidal ideation, and−0.008 (Z=−7.00, 95% CI [−0.010, −0.007], p<0.001) in the pathway of parental attachment-peer attachment-suicidal ideation.

Conclusion: The study suggested that parental attachment could directly influence suicidal ideation and indirectly influence suicidal ideation via anhedonia and peer attachment. The results emphasized the importance of attachment in infancy and verified the feasibility of intervention on anhedonia and peer attachment to prevent suicidal ideation.

Replication Studies on Significant Differences in Personality Profiles of Securely and Insecurely Attached Psychotherapists and Dentists

This study contributes to the therapist variable in general and the personality profile of securely and insecurely attached psychotherapists and other healthcare professionals in particular. In a preceding study, it has been found that insecurely attached psychotherapists differ in nine personality styles from securely attached ones. The aim of the present study was to replicate these findings and to investigate whether they also apply to other health professions such as dentists. About 891 subjects from two German professional societies for hypnosis were surveyed online with a personality questionnaire [Personality Styles and Disorder Inventory (PSDI)] and an attachment questionnaire [Relationship Scale Questionnaire (RSQ)]. Since these subjects were interested in hypnosis and used it in their practice (HYP), 150 dentists without a hypnosis context (NONHYP) were studied as a control group with the same survey. The results of the preceding attachment study could be replicated: Insecurely attached healthcare professionals differed significantly from securely attached ones in the same nine (plus one, i.e., 10) personality styles if they use psychological methods including hypnosis. If they do not use psychological methods (like the NONHYP dentists), they differ in half of the personality styles. No within-sample and no between-sample differences have been found in the assertive/antisocial (AS) personality style. No within-sample differences have also been found in the conscientious/compulsive (ZW) and the intuitive/schizotypal (ST) personality styles. However, large between-sample differences were obvious in ZW and the ST. Both of the samples of the dentist were much more compulsive than the two psychotherapeutic samples. In addition, both of the HYP samples were much more schizotypal than the NONHYP samples. The latter is the general signature of those individuals who are interested in hypnosis and were metaphorically termed homo hypnoticus. It seems that AS, ZW, and ST are independent of attachment.

Psychological Distress in Erectile Dysfunction: The Moderating Role of Attachment

Introduction

In clinical consultations, men with erectile dysfunction do not always express personal, sexual, and interpersonal concerns.

Aim

We explore whether the attenuated impact of erectile dysfunction may be explained by a regulation of negative affect that causes activation of the attachment system.

Methods

The study sample consisted of 69 men diagnosed with erectile dysfunction, mean (SD) age 56 (10.83) years. Participants completed self-reported questionnaires to assess erectile dysfunction severity, attachment style, sexual satisfaction, relationship satisfaction, and psychological symptoms.

Main Outcome Measure

The moderating role of attachment between erectile dysfunction and sexual satisfaction, relationship satisfaction, and psychological distress was evaluated using multiple linear regression and moderation analysis.

Results

All men in the sample had high attachment avoidance, distributed between the dismissive-avoidant (69.6%) and fearful-avoidant (30.4%) substyles, but low levels of psychological symptoms. Despite their erectile dysfunction, 27 patients (39.1%) rated their sexual life as satisfactory, and 46 (66.7%) rated their relationship with their partner as satisfactory. Men with fearful-avoidant attachment reported feeling more sexual desire and less sexual satisfaction than men with dismissive-avoidant attachment. Multiple linear regression analysis showed that sexual satisfaction variance was explained by erectile dysfunction severity, attachment anxiety, and relationship satisfaction scores. Moderation analysis showed that attachment anxiety, but not relationship satisfaction, moderated the impact of erectile dysfunction on sexual satisfaction.

Conclusion

The avoidance dimension of attachment, which tends to be high in patients with erectile dysfunction, involves deactivation of the sexual system in an effort to minimize the emotional distress associated with erectile dysfunction, which damages sexual and relationship intimacy and delays the decision to obtain professional help. The presence of high attachment avoidance and the moderating value of attachment anxiety allow us to propose specific treatments for these men.

Maestre-Lorén F, Castillo-Garayoa JA, López-i-Martín X, et al. Psychological Distress in Erectile Dysfunction: The Moderating Role of Attachment. Sex Med 2021;9:100436.

Insight and Outcome in Long-Term Psychotherapies of Depression

Objectives: In different therapeutic approaches, insight is acknowledged as an important part of patient's therapeutic change process. We examined whether the level of insight (1) differs between psychoanalytic (PA), psychodynamic (PD) and cognitive-behavioral therapy (CBT), and (2) predicts long-term symptomatic outcome. Methods: A completer sample of 67 depressed patients from the Munich Psychotherapy Study was analyzed. Symptoms were assessed with Beck Depression Inventory (BDI) and Symptom Checklist-Revised (SCL-90-R) at pre-treatment and three-year follow-up. Insight was assessed from 242 sessions of mid-therapy phase with the Experiencing Scale. Results: The general level of insight was higher in PA as compared to CBT, and associated with lower depressive symptoms (BDI) across all three therapeutic modalities at three-year follow-up. Insight was unrelated to general distress (SCL-90-R). Exploratory analyses suggested that patients treated with PA showed higher levels of insight especially in high quality sessions (assessed by therapist). Patients for whom the extent of insight was positively linked to session quality, suffered from more depressive symptoms at three-year follow-up than patients gaining insight when session quality was low. Conclusion: Insight differs between PA and CBT and may be a common change mechanism in long-term psychotherapies.

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.

Worthy and able: How helping relationships alter the trajectories of young people who face severe and multiple disadvantages

Relationships with professional helpers, partly resembling family relationships, have the potential to help young people facing severe and multiple disadvantages. The aim of this study was to document how relationships alter the trajectories of young people in these circumstances. Young people (n = 30) and support workers (n = 35) were identified by the leaders of 11 UK and 5 US not-for-profit organisations providing support for this population. Thematic analysis of the semi-structured interviews revealed that relationships helped young people feel positive about themselves, disrupted their maladaptive patterns of thinking, and fostered a sense of agency in themselves. The result was a self that was worthy and able. Findings provided an in-depth exploration of the notion of support in the context of adversity.

Attachment style, thought suppression, self-compassion and depression: Testing a serial mediation model

Attachment anxiety has been consistently linked with increased vulnerability to depression, and hyperactivating emotion regulation strategies (e.g., rumination) have been shown to mediate this relationship. Investigations of mediators of the attachment avoidance to depression relationship have yielded inconsistent findings, and the nature of this relationship remains to be clarified. There is evidence to suggest that the constructs of thought suppression and self-compassion are associated with attachment avoidance and also with depressive symptomology. In order to further clarify the nature of this relationship, the present study tested a serial mediation model, whereby it was hypothesised that thought suppression and self-compassion were serial mediators of the relationship between attachment avoidance and depression. One hundred and forty-eight participants completed an online composite questionnaire consisting of the Experiences in Close Relationships-Revised Questionnaire, the White Bear Suppression Inventory, the Self-Compassion Scale, and the Depression Anxiety and Stress Scale-21. Initial results supported the hypothesised serial mediation model (Model A); that is, higher attachment avoidance predicted higher thought suppression, higher thought suppression predicted lower levels of self-compassion and lower levels of self-compassion predicted higher depression. However, this model was no longer significant following the inclusion of attachment anxiety as a covariate within the post-hoc analysis. A second, post-hoc serial mediation model was tested (Model B), with the only difference being that attachment anxiety replaced attachment avoidance as the independent variable. This model was significant, with and without the inclusion of attachment avoidance as a covariate. The study provides evidence for the central role of thought suppression and self-compassion as mechanisms underlying the relationship between insecure attachment and depression, and indicates that these factors operate in opposing directions. The findings are discussed in terms of explicating some of the processes through which insecure attachment confers vulnerability to depression. The implications of the observed degree of shared variance between the two attachment dimensions suggests these constructs may be more appropriately considered overlapping, rather than orthogonal.

An exploration of the experience of trainee integrative psychotherapists on therapeutic alliance in the light of their attachment style

Therapeutic Relationship has been regarded as a profound element of the psychotherapeutic procedure and crucial for the outcome of therapy. Research evidence so far claims that both therapist’s and client’s personality can impact the Therapeutic Relationship. Based on the well-researched Attachment Theory there has been some research mostly focused on how clients’ attachment patterns can affect the Alliance. Limited research, though, on how therapists experience the Relationship in relation with their Attachment Styles do exist. The current study investigates trainee therapists’ experience of the Therapeutic Relationship in the light of their Attachment Style. A qualitative approach was used for this research to investigate in depth the experience of five trainee Integrative psychotherapists who were recruited to take part in semi-structured interviews. Interviews were transcribed and verbatim was divided into superordinate and subordinate themes and analyzed by Interpretative Phenomenological Analysis method. Four master themes were identified. Findings were then compared and discussed according to existing literature. All participants referred to the relevance of Attachment Theory in psychotherapy. They also agreed on the activation of their Attachment Styles during the therapeutic process. The securely attached therapist confirms previous studies on her capability to offer a secure base for her clients. On the other hand therapists with insecure Attachment Styles appeared sensitive in their collaboration mostly with insecure clients. Anxiously attached therapists proved to experience difficulty in the initial stages of the Therapeutic Relationship while the combination of avoidant therapist-avoidant client appeared to be the most demanding one, regarding the concept of trust and relationship ruptures. We suggest that the exploration of trainee therapists’ Attachment Styles as well as the study of the Attachment Theory should be added to all Counseling and Psychotherapy curricula regardless the therapeutic orientation because of its contribution to forming positive Therapeutic Relationships.

Exposure to animal suffering, adult attachment styles, and professional quality of life in a sample of Italian veterinarians

Contextual and individual risk factors of veterinarians’ professional quality of life are being debated. Research suggests that attachment styles are relevant predictors of professional quality of life; however, their role in work-related well-being of veterinarians is yet to be ascertained. In the present study, self-report measures on exposure to animal suffering, adult attachment styles, and professional quality of life were administered to 1,445 Italian veterinarians (70% females) aged 24 to 74 years old; sociodemographic information and information on workload were also collected. Female gender, higher levels of ordinary workload, on-call hours per week, exposure to animal suffering, together with fearful and preoccupied attachment styles were significantly associated with lower levels of veterinarians’ quality of life. This suggests that work-related factors may combine with individual psychological features in promoting or disadvantaging the professional quality of life of veterinarians. Implications of these findings for promoting veterinarians’ quality of life and directions for future research are discussed.

The Impact of Australian Psychologists’ Education, Beliefs, Theoretical Understanding, and Attachment on the Use and Implementation of Exposure Therapy

The objective of this study was to investigate the relative contributions of university education, exposure specific training, and beliefs about exposure therapy (ET) in relation to the frequency, duration, and intense delivery of ET by Australian psychologists. Associations between clinicians’ use of and theoretical conceptualisation of ET, and attachment style were also evaluated. A total of 115 Australian psychologists (N = 94 females) completed an online survey. Findings revealed that a majority of participants used cognitive behaviour therapy (93%) and ET (88%) to treat anxiety disorders, including obsessive-compulsive disorder. The majority who used ET (90%) reported using therapist-assisted in vivo exposure with clients. Findings also showed that therapists spend 42% of session time on exposure. Moreover, therapists who reported more comprehensive training had more positive beliefs about ET. Positive beliefs about ET, and clearer conceptualisation of treatment, were related to greater use and more intense implementation of ET. Psychologists with a more preoccupied or dismissive attachment style were less likely to deliver intense ET. The findings suggest that ET-specific training may be a powerful medium to improving the adoption and application of ET. Clinician's theoretical conceptualisation of ET and interpersonal attachment style are also worthy targets for future research and training in ET.

Lessons Learned: Forty Years of Clinical Work With Suicide Loss Survivors

The author has been a grief therapist in private practice for almost 40 years. The largest percentage of his clients have been suicide loss survivors, and in this article, the author reflects on the “lessons learned” about how grief therapy with survivors is both the same as, and very different from, work with clients bereaved after other types of losses. After briefly reviewing some of the empirical literature about differences between suicide bereavement and grief after other modes of death, the author argues that perhaps the most distinguishing and difficult aspect of a suicide loss is the “perceived intentionality” of the death, and the related “perceived responsibility” for the death. The author goes on to identify a number of tasks of psychological reintegration after a suicide loss that can serve as a template for treatment goals for clinicians and clients alike. These include the cultivation of a very specific type of secure and nurturing therapeutic alliance; extensive psychoeducation about suicide, trauma, and grief; the need to help the client repair the psychological continuing bond with the deceased; and providing gentle support for the survivor in rebuilding an assumptive world that has been shattered by the suicide of a loved one. Finally, the article concludes with a discussion of the clinical implications of these differences for work with suicide loss survivors.

Significant Differences in Personality Styles of Securely and Insecurely Attached Psychotherapists: Data, Reflections and Implications

This is a contribution to the research on the therapist variable aiming to improve effectiveness of psychotherapy. It is shown that attachment styles shape personality styles of psychotherapists in a favorable or unfavorable manner. Data on personality (PSDI) and attachment (RSQ) styles was collected from 430 psychological psychotherapists of the DACH countries using an online survey. The 88 insecurely attached psychotherapists differed significantly from their 342 securely attached colleagues in 9 of 14 personality styles: They were - even though well within normal range - more paranoid, borderline, schizoid, dependent, negativistic, self-sacrificing, avoidant, and depressive, as well as less optimistic. This corresponds to results of other researchers. Data regarding their effectiveness was not available. It is argued that a secure attachment style predispose to be a good psychotherapist. Yet, insecurely attached psychotherapists possibly compensate their adverse traits through self-therapy, continuous education, and supervision.

A Theoretical Exploration of Live Discharge from Hospice for Caregivers of Adults with Dementia

Patients with dementia may be discharged from hospice if their condition stabilizes. The loss of professional support and an already complex grief process needs careful attention. A live discharge presents a unique experience for each hospice patient, caregiver, and hospice team, which varies from traditional bereavement theories used to describe the grieving process. This article explores live discharge from hospice for caregivers of adults with dementia through a theoretical lens of Symbolic Interactionism (SI) and Attachment Theory (AT). The theories of SI and AT support and assist in understanding the experience of caregivers who lose hospice support due to ineligibility. In addition, caregivers watch the gradual deterioration and psychological loss of someone with dementia while they remain alive described as an ambiguous loss. Ambiguous loss as a subset of traditional bereavement theories provides a framework for this exploration and provides a relevant illustration of the complex needs. This article will conclude with implications for social work practice. It is important for hospice clinicians to be aware of current termination practices necessary to manage appropriate attachments, support the symbolic meaning of the hospice experience, validate the ambiguous losses, and maintain a sense of hope through a live discharge from hospice.

Patients' Adult Attachment Interview classification and their experience of the therapeutic relationship: are they associated?

In the last decade of his career, Jeremy Safran became increasingly interested in investigating the ways in which attachment representations influence the therapeutic relationship. In this paper, we test such influence in a sample of thirty outpatients who received Brief Relational Therapy by comparing their independently coded pre-treatment Adult Attachment Interview (AAI) with their narratives in a post-treatment interview about the relationship with the therapist (the Patient Relationship Interview at Termination, PRI-T). The PRI-T was coded with the following three measures: i) The Patient Attachment to Therapist Rating Scale (PAT-RS), which assesses the quality of the patient's attachment relationship to the therapist; ii) the Coherence scale from the AAI, adapted for use on the PRI-T; and iii) the Patient Attachment Classification System (PACS), which measures generalized differences in how individuals convey their experiences and feelings. Results suggest that patients' AAI predicts how they experience, represent, and communicate about the therapeutic relationship at the end of treatment, as shown by the PAT-RS, the Coherence scale adapted for use on the PRI-T, and the PACS applied to the PRI-T. These findings lend support to Safran and others' hypothesis that patients' AAI-status plays a role in patients' representations of the relationship with the therapist.

A Step Toward a Better Understanding of the Relationship Between Victimization and Emotional Distress: Indirect Effect of Adult Attachment and Interaction With Household Dysfunction

A history of victimization has been linked to the latter development of emotional distress. However, not all victims develop emotional distress in response to victimization, emphasizing the need to identify mediators that can guide intervention, as well as moderators to more targeted preventive actions. Within a developmental psychology framework, we aimed to test two models: (a) the role of adult attachment as a mediator in the relationship between victimization and emotional distress, and (b) the role of household dysfunctions as moderators in the relationship between victimization and emotional distress, in psychiatric patients. Participants were 120 adult psychiatric patients, between ages 20 and 79 years (M = -47.22, SD = 13.102) that responded to questions assessing household dysfunction in the family of origin, victimization, and adult attachment. Results revealed that adult attachment was a significant mediator in the association between victimization and emotional distress. Parental mental disorder and total household adversity were significant moderators for that same association. These results provide important clues for intervention. The focus on promoting secure adult relationships may contribute not only to the psychosocial adjustment of psychiatric patients but also to a healthier family functioning. Reducing the household dysfunction may provide a protective environment for the development of children, promoting a positive psychosocial adjustment, also preventing the intergenerational transmission of violence, insecure attachment, and emotional distress.

Ideal and actual partner assessments in male batterers with different attachment styles

Research analyzing male batterers' views of what constitutes an ideal partner is scarce, and rejected features have not been tested. Analyzing the association of attraction and rejection patterns with attachment could help us understand how these men choose their female partners and the biases that make violence against these women more likely. The objective of this study was to analyze these patterns in male batterers with different attachment styles, considering both their ideal and actual partner assessments and the discrepancies between the two. Participants were 108 male offenders who were serving sentences in Colombian prisons for violence against women. In addition to identifying their attachment styles (secure, dismissive, preoccupied, and fearful), the study had participants assess their ideal and actual partners. The results showed significant differences in their actual partner assessments and in ideal-actual partner discrepancies, but not in their ideals. Secure attachment was related to the best partner assessments (higher scores in positive features and lower scores in negative ones), whereas the fearfully attached participants stood out for showing the worst assessments (higher scores in negative features and lower scores in positive ones). The findings provide evidence of the association of attachment styles with attraction and rejection patterns and offer suggestions for tailoring interventions.

Why therapists should walk the talk: The theoretical and empirical case for personal practice in therapist training and professional development

The key proposition of this invited essay is that personal practice (PP), coupled with self-reflection, is central to the development of the most effective therapists. To date, the discussion about personal practice in therapist training and professional development has largely revolved around the value of personal therapy, subscribed to by some schools of psychotherapy but not by others. However, since the turn of the century a new landscape of personal practices for therapists has emerged. In particular, two forms of personal practice, meditation programs and self-practice/self-reflection (SP/SR) programs, have developed a growing evidence base. Here it is proposed that there is now a strong theoretical and empirical case to accord personal practice an explicit role in therapist training and professional development. The case rests on recent research suggesting that: (1) personal and interpersonal qualities of therapists play a key role in client outcomes; and (2) personal practice is the most effective way to achieve changes in therapists' personal and interpersonal qualities. It is suggested that the research agenda needs to move beyond asking whether or not personal practice is effective towards a more sophisticated set of questions: what personal practice, facilitated by whom, is most effective with which practitioners, in what contexts, at what point in time? To make further progress, trainers and researchers need to be supported to include personal practices in therapist training and to undertake research to evaluate their impacts.

Assessing adult attachment: Relation and validity of two dynamic-maturational model approaches

Assessing attachment is essential yet challenging. The Adult Attachment Interview (AAI) provides the best appraisal of adult attachment but is time-intensive and costly. Likewise, concerns have been raised regarding the Berkeley-AAI coding and classification method. Meanwhile, self-report measures of adult attachment are time-efficient and low-cost, but their validity is questionable. The Dynamic-Maturational Model approach to the AAI (DMM-AAI) and a novel self-report measure – the Attachment Relationship Questionaire (ARQ) – may offer a solution. However, additional investigations regarding the validity of DMM-AAI are needed and the ARQ’s psychometric properties have not be tested. The validity of the DMM approach to the AAI and the predictive relationship between the ARQ and DMM-AAI classification were examined for 212 participants living the UK. Results indicated a strong positive relationship between high numbered attachment classification on the DMM-AAI and psychological treatment status, χ²(6) = 56.07, p < .001; Cramer’s V = .371, p < .001. Binomial logistic regressions between the ARQ and DMM-AAI found both single-statement and multi-statement predictive models were statistically significant. However, the ARQ accounted for only a small amount of the variance (R² ≤ 0.15). In conclusion, the DMM-AAI demonstrated strong construct validity, whereas the ARQ is not useful for assessment of adult attachment. Further investigation with a revised version of the ARQ that addresses psychometric concerns is suggested.

'Modelling a Secure-Base' for Women with Complex Needs: Attachment-Based Interventions Used by Perinatal and Infant Mental Health Clinicians

Infant well-being is intrinsically linked to maternal physical and emotional well-being. Internationally health services have implemented policies to identify women at risk of mental health problems and developed effective care pathways. The aim of this paper is to describe how perinatal and infant mental health clinicians perceive their role and the attachment-based interventions they use in their work. The study comes from a larger mixed methods study, which examined two specialist perinatal and infant mental health services in New South Wales (Australia). Two hundred and forty-four medical records were reviewed, and six perinatal and infant mental health clinicians participated in in-depth semi-structured interviews. Data were analysed by content and thematic analysis. One overarching theme, modelling a secure base and three supporting themes, enhancing reflective capacity, enhancing emotional regulation and enhancing empathy emerged from the analysis. These findings demonstrate how perinatal and infant mental health clinicians use attachment theory to inform practice by modelling "holding" and being a secure-base for women. They also provide a clearer understanding of perinatal mental health practice and can be used to inform educational programs for multidisciplinary mental health professionals particularly those working with women and infants.

Positive Social Interactions in a Lifespan Perspective with a Focus on Opioidergic and Oxytocinergic Systems: Implications for Neuroprotection

In recent years, a growing interest has emerged in the beneficial effects of positive social interactions on health. The present work aims to review animal and human studies linking social interactions and health throughout the lifespan, with a focus on current knowledge of the possible mediating role of opioids and oxytocin. During the prenatal period, a positive social environment contributes to regulating maternal stress response and protecting the fetus from exposure to maternal active glucocorticoids. Throughout development, positive social contact with the caregiver acts as a “hidden regulator” and promotes infant neuroaffective development. Postnatal social neuroprotection interventions involving caregiver–infant physical contact seem to be crucial for rescuing preterm infants at risk for neurodevelopmental disorders. Attachment figures and friendships in adulthood continue to have a protective role for health and brain functioning, counteracting brain aging. In humans, implementation of meditative practices that promote compassionate motivation and prosocial behavior appears beneficial for health in adolescents and adults. Human and animal studies suggest the oxytocinergic and opioidergic systems are important mediators of the effects of social interactions. However, most of the studies focus on a specific phase of life (i.e., adulthood). Future studies should focus on the role of opioids and oxytocin in positive social interactions adopting a lifespan perspective.

The ebbs and flows of attachment: Within-person variation in attachment undermine secure individuals' relationship wellbeing across time

Although attachment security is relatively stable over time, individuals do experience significant within-person variation in their attachment security across time. No research to date, however, has assessed the relational consequences of within-person variation (fluctuations) in attachment security toward a specific attachment figure. Study 1 (N = 409) first examined whether attachment security was associated with individuals' expectations that their current intimate relationship would be stable and consistent over time (vs. inconsistent and unstable). Studies 2 and 3 extended this by examining the prevalence and consequences of actual within-person variation (fluctuations) in relationship-specific attachment security toward an intimate partner in 2 multiwave longitudinal studies that assessed individuals (Study 2, N = 324) and couples (Study 3, N = 171 dyads). The results indicate that secure individuals (those low in attachment anxiety or attachment avoidance) expect their current relationship to remain relatively stable and consistent over time (Study 1). However, Studies 2 and 3 demonstrated that most individuals do experience fluctuations in their relationship-specific attachment security. Moreover, greater fluctuations predict declines in relationship satisfaction (Studies 2 and 3) and increases in relationship distress (Study 3) over time, but primarily for secure individuals (those low in baseline attachment anxiety or attachment avoidance). This set of findings highlight the importance of examining within-person fluctuations in attachment security, which are associated with declines in trajectories of relationship wellbeing, particularly for secure individuals who anticipate greater stability in their relationships. (PsycINFO Database Record