Therapist Attachment Research Articles

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.

The Role of Therapists' Attachment and Introject in Their Treatment Process and Outcome: A Systematic Review.

Previous reviews have examined empirical evidence of the relationship between therapists' internalized relational models, including therapists' attachment styles and Sullivan's notion of introject, and the therapeutic relationship. This review expands upon previous reviews by examining the effect of therapists' internalized relational models on the treatment process (e.g., therapeutic alliance and countertransference) and treatment outcomes (e.g., symptoms and functioning) more broadly. Our systematic search identified 42 empirical studies measuring therapist's internalized relational models, defined as therapist attachment style (i.e., the way the therapist relates to others) and/or introject (i.e., the way the therapist relates to themselves), in relation to therapy process and outcome, including 35 studies on attachment, nine studies on introject and two that examined both constructs. A rigorous quality assessment was conducted; two studies were rated as 'moderate', and 40 were rated as 'weak' in quality. Based on the study findings, it appears that more securely attached therapists may have stronger working alliances and more positive therapeutic processes with their patients. Contrary to expectations, therapist attachment security does not appear to impact treatment outcomes. Therapists who relate to themselves in a more affirming way may have stronger working alliances and better treatment outcomes, but very few studies have addressed this question thus far. More rigorous research, especially on the effect of therapists' introject, is needed. Therapists may consider the potential impact of their internalized relational models on the working alliance and other treatment processes that influence therapeutic outcomes.

Retraction of Robinson et al. (2015).

Reports the retraction of "Crying as communication in psychotherapy: The influence of client and therapist attachment dimensions and client attachment to therapist on amount and type of crying" by Noah Robinson, Clara E. Hill and Dennis M. Kivlighan Jr. (Journal of Counseling Psychology, 2015[Jul], Vol 62[3], 379-392). The following article is being retracted (https://doi.org/10.1037/cou0000090). This retraction is at the request of coauthors Kivlighan and Hill after the results of an investigation by the University of Maryland Institutional Review Board (IRB). The IRB found that the study included data from between one and four therapy clients of the Maryland Psychotherapy Clinic and Research Laboratory (MPCRL) who either had not been asked to provide consent or had withdrawn consent for their data to be included in the research. Robinson was not responsible for obtaining and verifying participant consent but agreed to the retraction of this article. (The following abstract of the original article appeared in record 2015-23479-001.) Nelson (2005) associated 3 types of crying (inhibited, protest, despair) with 3 dimensions of attachment (avoidant, anxious, and secure). To test this theory, trained judges rated the intensity of inhibition, protest, and despair in 347 crying episodes for 40 clients and 14 therapists in 1,074 psychotherapy sessions. Crying occurred once out of every 7 sessions, and usually was characterized by protest or inhibition. Pre-therapy attachment dimensions of both therapist and client influenced crying. Therapists with high attachment avoidance had clients who cried frequently but less over time, whereas therapists with high attachment anxiety had clients who cried with more protest over time. Clients with high attachment anxiety initially cried with more protest and inhibition, but decreased over time, whereas clients with low attachment anxiety increased protest over time. Throughout the course of psychotherapy, therapists who were seen by their clients as establishing a secure attachment elicited more overall crying and a higher intensity of protest, whereas therapists who were seen by their clients as establishing insecure attachments had clients who cried less. Clients who established a secure or avoidant relationship with their therapists, relative to other clients of that therapist, cried infrequently and with inhibition, whereas clients who established a preoccupied relationship cried relatively often. Changes are suggested for Nelson's (2005) typology. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Therapist initial attachment style, changes in attachment style during training, and client outcome in psychodynamic psychotherapy.

This study extended the cross-sectional therapist attachment literature by examining longitudinal changes of therapist attachment avoidance and anxiety in relation to client treatment outcome. Data consisted of 942 Outcome Questionnaire-45 assessments (Lambert et al., 1996, 2004) of 213 clients working with 30 therapists from a university clinic that provided psychodynamically/interpersonally oriented individual therapy, and yearly therapist self-report of attachment styles using the Experience in Close Relationships Scale (Brennan et al., 1998) over 2-4 years of training at a university clinic. Using multilevel growth modeling, we found that initial attachment anxiety or avoidance alone were not associated with treatment outcomes. Instead, therapists with small increases in attachment avoidance, from a low avoidance baseline, were more effective in helping clients reduce psychological distress than their peers. Findings suggest that small increases in attachment avoidance may be a beneficial development for trainees, as it may reflect a process of learning emotional boundary regulation (Skovholt & Rønnestad, 2003) and taking on the observer aspect of the participant-observer role (Sullivan, 1953). Current findings challenged the assumption that higher therapist attachment avoidance and anxiety is always associated with worse client outcome and suggested the importance of continuous self-reflection to understand how one's own attachment change impacts their clinical practice. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Working alliance after transferring from one therapist to another in a training clinic: Influence of therapist attachment style.

This study investigated how client working alliance changed after transferring from one therapist to another: (a) When pre- and post-transfer therapists' attachment anxiety/avoidance were congruently higher or lower and (b) when the pretransfer therapists' attachment anxiety/avoidance were more or less discrepant from the posttransfer therapists. A Tau-U analysis and a multilevel polynomial regression and response surface analysis were used to analyze longitudinal data about 23 transferred clients in open-ended psychodynamic psychotherapy with doctoral-level therapist trainees (n = 29). When first and second therapists' attachment anxiety/avoidance levels were congruent, the higher the two therapists' attachment anxiety and avoidance levels were, the greater was the decrement in clients' ratings of working alliance after transfers. When first and second therapists' attachment anxiety/avoidance levels were discrepant from each other, the more the first and second therapists' attachment were different from each other in terms of anxiety, the greater decrement in clients' ratings of working alliance there was after transfers. Meanwhile, the more the two therapists' attachment avoidance levels were different from each other, the less decrement in clients' ratings of working alliance there was after transfers. Therefore, the attachment orientations of the pre- and post-transfer therapists combined to influence client working alliance after transfers. Limitations and implications of the present research are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

Patient's and the Therapist's Attachment Representations, Attachment to Therapists, and Self-Esteem-Change Through Psychotherapy.

Objectives: The present naturalistic study aims to investigate the differential effects of the patient’s and the therapist’s attachment representations on the attachment to the therapist as perceived by the patient, and their impact on self-esteem-change through psychotherapy.Methods: Attachment variables of N = 573 patients as well as N = 16 therapists were assessed. Attachment representations were measured for therapists and patients via the Bielefelder Questionnaire for Client Attachment Exploration, the Relationship Specific Attachment to Therapist Scales and the Adult Attachment Interview. The patient’s attachment to therapists was evaluated and patients’ self-esteem was measured via the Frankfurter Selbstkonzeptskalen at the beginning and end of psychotherapy.Results: Although there were significant effects of the patient’s attachment representations on the perceived attachment to the therapist as well as between the perceived attachment to the therapist and the amount of self-esteem-change, the therapist’s attachment style had no significant influence on the perceived attachment to the therapist.Conclusion: Self-esteem-change through psychotherapy is influenced by the actually formed attachment relationship as perceived by the patient. The patient’s attachment representations but not the therapist’s attachment style contributes to the actual patient’s attachment to the therapist.

Retiring in the time of Covid and Donald Trump: the impact of the therapist's attachment style on maintaining connection over Zoom

The therapist's retirement is not widely written about in psychoanalytic literature. The physical requirements to do our job are minimal, hence it is often possible to keep working long into advanced age. Self-esteem and identity, fuelled by our work, are hard to disrupt. Pressure to maintain one's status as a working professional is also a factor. The therapist's attachment style may contribute to prolonging the decision to retire, if they have a significant need for the emotional and intellectual stimulation derived from the work. The experience of ending many long treatments over Zoom and the telephone, surrounded by the chaos of the pandemic and the political situation in the United States, was profoundly impacted by my attachment style, making it harder to locate myself in my patients' experience.

Therapeutic distance in client-therapist narratives: client attachment, therapist attachment, and dyadic effects

Based on the attachment framework, therapeutic distance conceptualization focuses on closeness–distance dynamics in the therapeutic relationship. We aimed to evaluate the psychometric properties of the Therapeutic-Distance-Scale, Observer-version (TDS-O) and apply a dyadic approach to examine associations between attachment characteristics and therapeutic distance experiences of clients, therapists, and mutual effects. Sixty-six clients and their 29 therapists completed the ECR and relational narratives collected in RAP interviews at early, mid, and late psychodynamic-therapy were rated on TDS-O scales: too close, too distant, autonomy, and engagement. The TDS-O showed good IRR, internal reliability and content validity. Client anxiety was not associated with therapeutic distance but associated with autonomy. Client avoidance associated with clients’ experiencing therapist as too close, and lower engagement only at early therapy, but was not associated with therapists’ experience. Therapist anxiety was not related to closeness–distance at early therapy but related to gaps between client and therapist experiences at mid and late therapy. Therapist avoidance related to clients experiencing therapists as too close and granting less autonomy at early and mid-therapy, and to therapist experience of distance at late therapy. The findings underscore the importance of therapists’ regulating therapeutic distance through attunement to client’s interpersonal needs and therapy phase.

Therapist-client agreement about their working alliance: Associations with attachment styles.

Recent research on attachment in therapy indicates that therapist attachment style is related to therapists' agreement with their clients on the quality of their working alliance (WA; Kivlighan & Marmarosh, 2016). This study builds on these findings by examining how both the therapist's and the client's attachment style may be related to their agreement on the WA. The authors expected that less anxious and less avoidant clients working with less anxious and less avoidant therapists would have higher WA agreement. Using hierarchical linear modeling, they analyzed archival session data from 158 clients and 27 therapists at a community clinic. In terms of overall level agreement (averaged across sessions), therapists and clients significantly disagreed on their WA ratings, with therapists rating the WA lower than did their clients; but there was more therapist-client level-agreement when therapists had relatively less attachment avoidance. In terms of (linear) WA agreement from session to session, the authors found no main effects for either therapist or client attachment style alone, but several significant interactions between therapist and client attachment styles. Session-to-session agreement on the WA was higher when clients and therapist had "matching" (both higher or both lower in attachment anxiety or attachment avoidance) or "complementary" (one higher in attachment avoidance, the other lower in attachment anxiety, or one higher in attachment anxiety, the other lower in attachment avoidance) attachment styles than when styles were noncomplementary. The authors discuss these findings in terms of the attachment-related communication, signaling, and behavior that may be occurring in therapy dyads. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Attachment-security prime effect on skin-conductance synchronization in psychotherapists: An empirical study.

Physiological synchronization (PS) is a phenomenon of simultaneous activity between two persons' physiological signals. It has been associated with empathy, shared affectivity, and efficacious therapeutic relationships. The aim of the present study was to explore the possible connections between PS and the attachment system, seeking preliminary evidence of this link by means of an experimental manipulation of the sense of attachment security in psychotherapists according to a protocol by Mikulincer and Shaver (2001), which has been proven to elicit empathetic behavior. We compared the synchronization of skin-conductance signals in brief psychological interviews between 18 psychodynamic therapists and 18 healthy volunteers. A sense of attachment-security priming was administered to half of the therapists, whereas the other half received a positive-affect control prime. Lag analysis was performed to investigate the "leading" or "following" attitudes of the participants in the two conditions. Mixed-model regressions and evidence-ratio model comparisons were used to investigate the effects of the manipulation on PS. Therapist attachment anxiety and avoidance traits were considered covariates. The attachment-security prime showed a significant effect on PS lag dynamics, but not on overall PS amount. Lag analysis showed that the therapists in the attachment-security condition were significantly more prone to assume a leading attitude in the physiological coupling than the therapists in the control condition. Therapist attachment anxiety and avoidance had no apparent effect. Our result paves the way for further exploration of the clinical relationship from a physiological standpoint. (PsycINFO Database Record

The Complexity of Loss During a Forced Termination: A Case Illustration

The end of a therapeutic relationship is experienced in a unique way by each patient and triggers complex feelings relating to early attachment issues, losses and traumas. It is an immense rupture: a process of attachment and separation, intimacy and loss that is an emotionally intense experience for both participants. This case illustration provides insight into the difficulties experienced during the process of forced termination in an analytic community‐training clinic. Following a 2‐year treatment, Peter, a patient who had been severely traumatized in youth, had to tolerate the pain of another loss; having to say goodbye to a therapist. We describe the therapist's initiation and engagement of the termination phase. A series of measurements of patient personality, therapist attachment, and change in alliance and outcomes provide information on the impact of Peter's history and the therapeutic relationship. Clinical illustrations highlight different parts of the decision‐making process in terms of the patient's sensitivity to loss, as well as the therapist's uncertainty around self‐disclosure. We suggest ways therapists may facilitate endings by addressing positive and negative feelings, providing a good‐enough attachment experience, and stimulating an internalization of the therapeutic relationship. Implications for clinical practice, research and supervision are discussed.

Therapist's Empathy, Attachment, and Therapeutic Alliance: Neurobiological Perspective

This paper discussed the relationships between therapist’s empathy, attachment between therapist and client, and therapeutic alliance in a neurobiological context. There are some interrelated areas of brain function such as mirror neurons, the middle prefrontal cortex, and the ventrolateral prefrontal cortex regarding the relationships between empathy, attachment between therapist and clients, and therapeutic alliance. Clinical implications were also discussed. Understanding the interrelationships between therapist’s empathy, attachment, and therapeutic alliance in therapy in brain function may contribute to better treatment for clients. Also, a therapist may have more confidence based on understandings of these interrelationships.

A Pilot Study Implementing Coping Power in Italian Community Hospitals: Effect of Therapist Attachment Style on Outcomes in Children

The study presented the initial report of a project regarding the implementation of the Coping Power Program in Italian community hospitals, and the program’s ability to reduce externalizing behavioral problems in children with a Disruptive Behavior Disorder diagnosis. Usually, interventions for children are implemented by a number of therapists with different personal characteristics, which therefore influence the implementation quality of an intervention. That said, the present study aimed to establish whether the insecure attachment styles of therapists predict unfavorable outcomes for children treated with the Coping Power Program. The sample included 80 children with a Disruptive Behavior Disorder diagnosis and 16 therapists. The results showed that the change in children’s aggressive behavioral problems was significantly related to the levels of the therapist’s preoccupation with relationships. Higher levels of change in aggression (where a higher value means that the aggression at the end of the treatment is higher than aggression at the baseline evaluation) are associated with higher levels of therapist’s preoccupied attachment style (anxious attachment style). This study provided some preliminary evidence that therapists need to be sensitive to their own attachment experiences when delivering therapy for children.

A Systematic Review of the Effect of Therapists' Internalized Models of Relationships on the Quality of the Therapeutic Relationship.

Previous reviews have found equivocal evidence of an association between therapists' internalized relational models and the therapeutic relationship and have neglected empirical literature based on Sullivan's notion of introject. This review expanded upon previous reviews to examine the effect of therapist internalized relational models on a broader conceptualization of the therapeutic relationship. Systematic search processes identified 22 papers measuring therapist attachment and/or introject and therapeutic relationship: 19 on therapist attachment, 5 on introject with 2 overlapping. Overall, despite heterogeneity in design and variable methodological quality, evidence suggests that therapist attachment affects therapeutic relationship quality, observed in client-rated evaluation, therapist negative countertransference, empathy, and problems in therapy. Interaction effects between client and therapist attachment style were also found. Evidence suggesting that therapist introject also affects therapeutic relationship quality, including therapists' manner and feelings toward their clients, was stronger. Evidence clearly shows that therapists' internalized relational models affect the therapeutic relationship. More research is necessary to clarify exactly how therapist and client internalized relational models interact and translate these findings into clinical practice.

Therapist Reflective Functioning, Therapist Attachment Style and Therapist Effectiveness.

This study investigated the relationship between two therapist attributes (reflective functioning and attachment style) and client outcome. Twenty-five therapists treated a total of 1001 clients. Therapists were assessed for reflective functioning and attachment style using the Adult Attachment Interview and the Experiences in Close Relationships Scale. Clinical outcome was measured using the Outcome Questionnaire (OQ-45). Data were analysed using hierarchical linear modelling. Results indicated that therapist reflective functioning predicted therapist effectiveness, whereas attachment style did not. However, there was evidence of an interaction between therapist attachment style and therapist reflective functioning. Secure attachment compensated somewhat for low reflective functioning and high reflective functioning compensated for insecure attachment. Possible implications for the selection of therapy training candidates and therapist training are discussed.

The quest for connection in interpersonal and therapeutic relationships

Objective: This paper focuses on the need for connection as a common core theme at the heart of both close relationships and therapeutic relationships and explores ways to connect these two research domains that have evolved as separate fields of study. Bowlby's attachment theory provides a strong conceptual and empirical base for linking human bonds and bonds in psychotherapy. Method: The growing body of research intersecting attachment and psychotherapy (1980–2014) is documented, and meta-analytic studies on attachment–outcome and attachment–alliance links are highlighted. Results: Five ways of studying attachment as a variable in psychotherapy are underscored: as moderator, as mediator, as outcome, client–therapist attachment match, and as process. By integrating conceptualizations and methods in studying relational narratives of client–therapist dyads (Core Conflictual Relationship Theme), measures of alliance, and client attachment to therapist during psychotherapy, we may discover unique client–therapist relational dances. Conclusions: Future fine-grained studies on how to promote core authentic relational relearning are important to clinicians, supervisors and trainers, who all share the common quest to alleviate interpersonal distress and enhance wellbeing. Directions for advancing research on interpersonal and therapeutic relationships are suggested. Learning from each other, both researchers of close relationships and of psychotherapy relationships can gain a deeper and multidimensional understanding of complex relational processes and outcomes.

Crying as communication in psychotherapy: The influence of client and therapist attachment dimensions and client attachment to therapist on amount and type of crying.

Nelson (2005) associated 3 types of crying (inhibited, protest, despair) with 3 dimensions of attachment (avoidant, anxious, and secure). To test this theory, trained judges rated the intensity of inhibition, protest, and despair in 347 crying episodes for 40 clients and 14 therapists in 1,074 psychotherapy sessions. Crying occurred once out of every 7 sessions, and usually was characterized by protest or inhibition. Pre-therapy attachment dimensions of both therapist and client influenced crying. Therapists with high attachment avoidance had clients who cried frequently but less over time, whereas therapists with high attachment anxiety had clients who cried with more protest over time. Clients with high attachment anxiety initially cried with more protest and inhibition, but decreased over time, whereas clients with low attachment anxiety increased protest over time. Throughout the course of psychotherapy, therapists who were seen by their clients as establishing a secure attachment elicited more overall crying and a higher intensity of protest, whereas therapists who were seen by their clients as establishing insecure attachments had clients who cried less. Clients who established a secure or avoidant relationship with their therapists, relative to other clients of that therapist, cried infrequently and with inhibition, whereas clients who established a preoccupied relationship cried relatively often. Changes are suggested for Nelson's (2005) typology.

Client and Therapist Attachment Styles and Working Alliance.

Working alliance has been shown to be important in influencing the outcome of therapy. Research evidence suggests that characteristics of both clients and therapists impact on the development of the working alliance. Although attachment theory is well researched, there is relatively limited research on the relationship between both therapist and client attachment style and the working alliance; traditionally, research has placed greater emphasis on client characteristics. The current study examines the extent to which both client and therapist self-reported attachment styles are related to the working alliance. Thirty clients and 42 therapists were recruited from primary care psychology services. Thirty client-therapist dyads were examined. Participants completed self-report measures of anxiety and depression, attachment style and working alliance at a single time point. Client and therapist attachment security were not independently related to working alliance. However, there was a significant association between therapist insecure attachment and alliance in more symptomatic clients. There was also some evidence that therapists and clients with oppositional attachment styles reported more favourable alliances. The study suggests that the relationship between therapist attachment style and alliance is not straightforward. It is likely that the complexity of clients' presenting problems, coupled with interaction between client-therapist attachment styles, influences the therapeutic alliance. Therapist insecure attachment may negatively affect the therapeutic alliance in more symptomatic clients. It is important to consider the interaction between client and therapist attachment and how these interactions influence the therapeutic alliance. Therapists should be aware of their own personal attachment style and reflect on how this might manifest during the therapeutic process.

Novice therapist attachment and perceived ruptures and repairs: A pilot study.

Although extensively discussed in theoretical articles, empirical studies of therapist attachment and perceptions of ruptures and repairs are lacking. The present study examined the relationship between therapist attachment anxiety and avoidance and their perceptions of rupture tension, effort, and repair. Twenty-two novice therapists completed a measure of adult romantic attachment and a measure to assess perceptions of ruptures and repairs following the eighth session with their first clients. Results revealed that there was a strong positive correlation between therapist attachment anxiety and effort spent focused on perceived ruptures and a moderate positive correlation between attachment anxiety and rupture tension. There was no significant relationship between attachment anxiety and perceived repairs of ruptures. Attachment avoidance was not significantly correlated with either perceptions of the ruptures or repairs. Therapists who were higher on anxiety and avoidance, more fearful therapists, reported the most ruptures. Limitations and implications of the findings are presented.