The development of the client-therapist bond through the lens of attachment theory.

The bond between client and therapist, a component of the global alliance, is widely believed to play a crucial role in supporting the work of therapy. However, we know little about how the client-therapist bond becomes established and have few theoretical tools to conceptualize its development. Attachment theory, with its focus on the development and dynamics of intimate relationships, is a lens through which we can expand our understanding of the client-therapist bond. I argue that the therapeutic bond may be usefully viewed as an in-progress attachment to therapists. Using Bowlby (1969/1982) and Ainsworth's (Ainsworth et al., 1978) ideas about normative attachment development, I present a phase model of attachment to the therapist and include behavioral, cognitive, emotional, and physiological markers of each phase. I draw empirical support from the psychotherapy process and alliance literatures and discuss research considerations and clinical implications of the model. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attachment style.

This article provides a brief review of attachment theory and recent research studies on its implications for individual psychotherapy. Attachment theory offers a conceptual framework that helps illuminate how past experiences with caregivers might influence current transactions between therapist and patient. Both patients and therapists may form internal working models that are based, in part, on early experiences of interpersonal responsiveness. Such working models are reflected in secure, anxious-ambivalent, and anxious-avoidant attachment styles, which describe whether patients (and therapists) tend to be comfortable and confident in relationships, fearful of abandonment, or defensively separate. Recent studies showed that attachment styles in the context of therapy can be measured reliably and related to therapeutic process (e.g., the alliance) and outcome (e.g., treatment response). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Processes involved in client-nominated relationship building incidents: Client attachment, attachment to therapist, and session impact.

Thirty volunteer clients of trainee therapists nominated an incident that was critical in the development of their therapeutic relationship. Clients completed the Client Attachment to Therapist Scale (CATS), the Experiences in Close Relationships Scale (ECRS), and the Session Impacts Scale (SIS). Clients reported an increase in attachment security with their therapists, along with perceptions of support and relief and increasing exploration following the relationship building incident. While clients' avoidant attachment was unrelated to attachment to the therapist prior to the incidents, in subsequent sessions avoidance was related to a change in secure attachment to therapist. Finally, client attachment to therapist but not general attachment was significantly related to in-session exploration. Findings are discussed in light of attachment theory and convergence with findings from the field of social psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Attachment in psychotherapy.

Reviews the book, Attachment in psychotherapy by David J. Wallin (see record 2007-05421-000). This intellectual and clinical tour-de-force is what we have been waiting for: a book that is on the one hand a coherent, creative, thoughtful, and remarkably integrated view of contemporary psychoanalysis, with attachment, and attachment processes, at its core, and on the other a reflection on our daily, complex, work with patients. The book has three broad aims: first, to ground the reader in attachment theory and research, second, to broaden the reach of attachment theory by building bridges to other aspects of contemporary psychoanalytic theory and science, and third to apply this broader, deeply psychoanalytic, clinical attachment theory to understanding the dynamics of an individual patient and the dynamics of clinical work. This book should be essential reading for anyone interested in contemporary psychoanalysis. Few writers have the ability to write so directly and clearly about complex science and theory; his scholarship and reach are extraordinary. This book is also a book for therapists at all levels of experience. Throughout every section of the book, Wallin writes about his work with patients, about the therapeutic process, about the therapeutic situation, and about the therapeutic relationship, in all its complexity. In the end, he creates a truly contemporary vision of human development, affect regulation, and relational processes, grounded in the body and in the brain, and in the fundamental relationships that make us who we are, as therapists, as patients, and as human beings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client attachment to therapist: Relations to transference and client recollections of parental caregiving.

This study examined the relations between client attachment to the therapist and therapist perceptions of transference, as well as between client attachment and recollections of parental caregiving. Participants were 51 client-therapist pairs in ongoing therapy. After a therapy session, clients completed a measure of their attachment to their therapists and a measure of their perceptions of parental caregiving during childhood. Therapists rated levels of positive and negative, and amount of, client transference. Both secure and preoccupied-merger attachment were positively related to both negative transference and amount of transference. Level of avoidant-fearful attachment was not correlated with any type of transference. Insecure attachment to the therapist was associated with more negative recollections of parental caregiving. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The dance of attachment.

This paper unites two sets of research findings on attachment to provide some guiding ideas for the monitoring and alteration of insecure therapeutic relationships. Only individual therapy with adults is considered. The aim is to explain how empirical findings can produce a guiding theoretical understanding of what can be the changing momentary dynamics between client and therapist. It is assumed that therapists enable change from insecure to more secure types of relating. The paper does not claim that attending to attachment dynamics in therapy will promote psychological change by itself. However, what is suggested is recognizing the major forces within intimate meaningful relationships. It is possible to relate the empirical findings to the terms resistance and misempathy (a restatement of transference) via the details of the dynamics of relating. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The real relationship in psychotherapy: Relationships to adult attachments, working alliance, transference, and therapy outcome.

The purpose of this study was to understand how the real relationship (RR) relates to important process and outcome variables from both the clients’ and therapists’ perspectives. Using a sample of 31 therapist/client dyads at a university counseling center, the authors examined the RR at the 3rd session of therapy and at termination. The results revealed that client adult attachment avoidance was negatively correlated with client RR, while client adult attachment anxiety was uncorrelated. Therapists’ ratings of negative transference were negatively correlated with therapist-rated RR and were uncorrelated with client-rated RR. Hierarchical linear modeling analyses were conducted to predict postintervention outcome from client and therapist perceptions of the RR. Therapists’ ratings of the RR accounted for a significant amount of variance in client posttreatment symptoms while controlling pretreatment symptoms. Client-rated RR total scores and client and therapist 3rd-session alliance scores were not significant predictors of postsymptom ratings. Implications of the usefulness of measuring the RR in psychotherapy are discussed, as are recommendations for future study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Supporting affect regulation in children with multiple disabilities during psychotherapy: A multiple case design study of therapeutic attachment.

In a controlled multiple case design study, the development of a therapeutic relationship and its role in affect regulation were studied in 6 children with visual disabilities, severe intellectual disabilities, severe challenging behavior, and prolonged social deprivation. In the 1st phase, children had sessions with an experimental therapist stimulating therapeutic attachment, alternating with a control therapist providing positive personal attention only. In the 2nd phase, both therapists applied behavior therapy. Clients sought more proximity to the experimental therapist compared with the control therapist. Psychophysiological arousal (respiratory sinus arrhythmia and pre-ejection period) was lower when the experimental therapist applied behavior modification than when the control therapist did. Despite prolonged social deprivation, the attachment behavioral system appeared responsive to stimulation. The effects on affect regulation may explain the synergy between psychotherapy based on interpersonal and behavior modification approaches. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self-disclosure.

A review of the analog literature about therapist self-disclosure suggests that nonclients generally have positive perceptions of therapist self-disclosures. A review of the naturalistic psychotherapy literature indicates that therapist self-disclosure occurs infrequently, is used more often by humanistic-experiential than psychoanalytic therapists, is most often about professional background than about intimate personal details, is used for many different reasons, is used cautiously by therapists, and is helpful in the immediate process of therapy. Effects of therapist self-disclosure on the ultimate outcome of therapy are less clear. Limitations of the research (poor and inconsistent definitions and lack of a clinically appropriate methodology for studying self-disclosure) and guidelines for therapeutic practice are presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Countertransference, attachment, and the working alliance: The therapist's contribution.

This study examined the relationship among therapist attachment styles, countertransference behaviors, and working alliance. Fifty therapists in training and their supervisors participated in the study. Therapists completed a self-rated measure of attachment style and a measure of working alliance with 1 of their clients. Supervisors completed measures of working alliance and countertransference behaviors about their supervisee's relationship with the same client. Results indicate that therapist attachment style did not correlate with either countertransference behaviors or working alliance. However, negative countertransference was associated with poorer working alliances, and positive countertransference was related to a weak bond within the working alliance. Additional analyses indicate that disagreement among supervisors and therapists about the bond component was predictive of countertransference behaviors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client attachment to therapist: Relation to client personality and symptomatology, and their contributions to the therapeutic alliance.

This study examined the relation of client attachment to the therapist to diverse facets of the therapeutic alliance, client personality, and psychopathological symptoms, as well as the relative importance of therapeutic attachments, personality, and symptomatology in predicting the alliance. Eighty clients in ongoing therapy completed measures of client attachment to therapist (CATS), personality (6FPQ), psychopathological symptoms (BSI), and therapeutic alliance (WAI–Short, CALPAS, HAQ). Secure and Avoidant–Fearful attachment to the therapist correlated positively and negatively, respectively, with total and subscale alliance scores. Preoccupied-Merger therapeutic attachment was unrelated to the alliance. Exploratory analyses suggested however that the relationship between Preoccupied–Merger attachment and the alliance was moderated by the extent to which clients were distressed. Clients' therapeutic attachments were unrelated to basic personality dimensions. Preoccupied–Merger attachment to the therapist correlated significantly with several symptom dimensions. Clients' therapeutic attachments emerged as superior and more consistent predictors, relative to client personality and symptomatology, of the therapeutic alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Commentary on Dinger et al.: Therapist’s attachment, interpersonal problems and alliance development over time in inpatient psychotherapy.

This short article is a commentary on a research study investigating therapist and client attachment styles and their relationship to alliance development in a 12-week psychodynamic psychotherapy program for nonpsychotic inpatients. The relationship is complex; unsurprisingly, securely attached therapists with less distressed clients formed the strongest alliances. A significant proportion of therapists were insecure, almost entirely in the preoccupied or hyperactivating mode. It is argued that collusive relationships between such therapists and similarly overaroused clients may be common. Therapists need both to accommodate to their client’s attachment style and to confound it if positive change is to result. Therapist self-scrutiny is likely to be a precondition for such positive outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Congruence in nondirective play and filial therapy: Response to Ryan and Courtney.

Differences in the training of nondirective play therapists between University of York (U.K.) approach and the Guerney and Landreth approaches (U.S.) has been raised by Ryan and Courtney (2009). York-trained therapists are encouraged to initiate expression of their own feelings at selective times to assure that therapists are congruent in their relationship with children in nondirective play-therapy. Congruence, an important component of the necessary and sufficient conditions for therapeutic personality change (Rogers, 1957), is based on the importance of therapist genuineness to maintain a trustful and safe therapeutic relationship. This article compliments Ryan and Courtney (2009) for introducing the importance of congruence in play therapy. The assumptions of nondirective play therapy in the Guerney approach was influenced significantly by their development of filial therapy and to the training of parents and therapists, This article asserts that congruence, in the Guerney approach, is incorporated by therapists expressing their own feelings only when this is initiated overtly or covertly by the child. Responding to a child in this way is dependent on the empathic attunement to a child's emotional motivation by a skillful parent or therapist. This raises questions about whether a nondirective stance is maintained in the York approach. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Experienced therapists’ approach to psychotherapy for adults with attachment avoidance or attachment anxiety.

Interviews were conducted with therapists (N = 12) nominated by peers as especially effective in working with clients with adult interpersonal problems. Open-ended questions asked how these therapists would approach 2 adult clients described in brief vignettes as having high attachment avoidance or anxiety. A coding team used a grounded theory approach to identify 8 higher order themes in the interviews: Conceptualization, Client Defenses, Managing Boundaries, Markers of Progress, Therapist Reactions, Targeted Interventions, Corrective Relational Patterns, and Internal Representations and Models. These themes were integrated into an inclusive theoretical model based on the core concept of therapists’ strategic management of therapeutic distance. The distance necessary to engage clients initially is adjusted later in therapy to create a corrective attachment in the psychotherapy relationship that facilitates change. Therapists described how, after engagement, they gradually increase therapeutic distance for clients with attachment anxiety who must then manage resulting frustration while learning to function more autonomously. Therapists gradually insist on decreased therapeutic distance to help clients with attachment avoidance overcome their fears of intimacy. Therapists discussed the specific techniques they use to manage therapeutic distance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance.

Although the therapeutic alliance is a consistent predictor of psychotherapy outcomes, research has not distinguished between the roles of patient and therapist variability in the alliance. Multilevel models were used to explore the relative importance of patient and therapist variability in the alliance as they relate to outcome among 331 patients seen by 80 therapists (therapist average caseload was 4.1). Patients rated both the alliance and outcome and all models adjusted for baseline psychological functioning. The results indicated that therapist variability in the alliance predicted outcome, whereas patient variability in the alliance was unrelated to outcome. Reasons why therapist variability as opposed to patient variability predicted outcome are discussed. Clinical implications include therapists monitoring their contribution to the alliance, clinics providing feedback to therapists about their alliances, and therapists receiving training to develop and maintain strong alliances. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Verbal therapeutic behavior of expert psychoanalytically oriented, gestalt, and behavior therapists.

Asked 18 expert psychoanalytically oriented, gestalt, and behavior therapists to submit representative, audiotaped therapy interviews. A content analysis of therapist verbal behavior was conducted by means of the System for Assessing Therapist Communications, an instrument developed by the authors. Comparisons across the 3 theoretical orientations were made on 6 dimensions of behavior: type of therapeutic activity, temporal focus, interview focus, initiative, communication, and therapeutic climate. Results indicate that according to prediction, these expert therapists were similar in their communication of empathy, the basis for their therapeutic relationships. Theoretical orientation, however, differentially influenced the use of direct guidance and facilitative techniques, interview content focused on the client, therapist self-disclosure, therapist initiative, and supportive therapy climate. Gestalt therapists were most dissimilar from the other therapists. (14 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Parents' attitudes toward their child's therapist and therapy.

Parents of children in therapy typically have strong feelings and thoughts about their child's treatment, and their cooperation and support is often a critical aspect of successful treatment. Recent literature, in conjunction with the results of a small-scale study of 51 parents of children currently in treatment, suggests that contrary to classic psychoanalytic literature, parents experience primarily positive attitudes and feelings toward their child's therapist; they tend to feel hopeful, understood, and grateful. For the sake of both promoting and preserving therapeutic gains, therapists should actively pursue an alliance with parents and encourage their participation in their child's treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapists' view of therapeutic action in psychoanalytic psychotherapy with young adults.

Studying experienced therapists' implicit theorizing may contribute to our understanding of what is helpful and what hinders treatment with particular patient populations. In this study, 16 therapists' views of curative factors, hindering factors, and outcome were explored in 22 interviews conducted at termination of individual psychoanalytic psychotherapy with young adults. Grounded theory methodology was used to construct a tentative model of therapeutic action based on the therapists' implicit knowledge. The results indicated that developing a close, safe and trusting relationship was viewed as the core curative factor in interaction with the patient making positive experiences outside the therapy setting and the therapist challenging and developing the patient's thinking about the self. The therapeutic process was experienced as a joint activity resulting in the patient becoming a subject and acquiring an increasing capacity to think and process problems. The patient's fear about close relationships was seen as hindering treatment and leading to core problems remaining. The model is discussed in relation to major theories of therapeutic action in the psychoanalytic discourse and previous research focusing on young adults' view of curative and hindering factors in psychotherapy. Implications for practice and further research are suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Gender and representation in psychotherapy.

Investigated the ways in which patient and therapist gender influence the nature of patients' internalized representations of their therapist and the therapeutic relationship. A sample of 66 patients (29 males) completed the Therapist Representation Inventory (J. D. Geller et al, 1982), a self-report instrument designed to assess discrete properties of evoked representations. Results indicated widespread similarities between male and female patients in terms of the forms with which representations are evoked and the themes embodied in these representations. The differences that emerged suggest that women are more likely to keep their therapists in mind (and for longer periods of time) when working on their problems outside of therapy and that women with male therapists are especially likely to daydream about therapy and acknowledge missing their therapist in between sessions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Some factors affecting the quality of therapeutic relationships.

The degree to which the quality of the therapeutic relationship established by two equally "expert" therapists with the same patient sample varies in terms of the therapist's personality and his perceptions of the patients is investigated. "It was found that the therapist who was able to establish the better social relationships also established the better therapeutic relationships. Moreover the therapist who perceived a patient as more closely approximating his 'ideal patient' concept created the better relationship with that patient." 21 references. (PsycINFO Database Record (c) 2010 APA, all rights reserved)