self-reported attachment styles and therapeutic orientation of therapists and their relationship...

Self-reported attachment styles and therapeutic

orientation of therapists and their relationship

with reported general alliance quality

and problems in therapy

Susanna Black1*, Gillian Hardy2, Graham Turpin2 and Glenys Parry3

1Sheffield Care NHS Trust, UK2Department of Clinical Psychology, University of Sheffield, UK3Sheffield Centre for Health and Related Research, University of Sheffield, UK

The aims of this study were to explore the relationship between therapists’ self-

reported attachment styles and therapeutic orientation with the self-reported general

therapeutic alliance and therapist-reported problems in psychological therapy.

A sample of 491 psychotherapists from differing therapeutic orientations responded to

a postal questionnaire. The questionnaire contained standardized measures of

therapeutic alliance quality, attachment behaviours, a checklist of problems in therapy,

and a brief personality inventory.

Therapist-reported attachment styles generally explained a significant additional

proportion of the variance in alliance and problems in therapy, over and above variance

explained by general personality variables. Self-reported secure attachment style was

significantly positively correlated with therapist-reported general good alliance.

Self-reported anxious attachment styles were significantly negatively correlated with

good alliance, and significantly positively correlated with the number of therapist-

reported problems in therapy. Therapeutic orientation independently predicted a small

but significant amount of the variance in reported general alliance quality in addition to

that explained by attachment behaviours.

It is now widely believed that comparable outcomes are achieved by different therapies

despite differences in their underlying assumptions about the development of

psychological dysfunction, and in therapeutic techniques employed (e.g. Horvath &

*Correspondence should be addressed to Dr Susanna Black (e-mail: [email protected]).

TheBritishPsychologicalSociety

363

Psychology and Psychotherapy: Theory, Research and Practice (2005), 78, 363–377

q 2005 The British Psychological Society

www.bpsjournals.co.uk

DOI:10.1348/147608305X43784

Greenberg, 1994; Luborsky, McClellan, Diguer, Woody, & Seligman, 1997). Horvath and

Greenberg (1994) have suggested that this raises fundamental questions about which

elements of therapy are responsible for change.

Psychotherapy research has shown that differences in both therapeutic approach,

and/or differences between client groups only account for a small proportion of the

outcome variance (Beutler, 2002). In contrast, one fairly consistent finding has been that

the quality of the therapeutic alliance, particularly in the initial stages of therapy, is

predictive of outcome (Martin, Garske, & Davis, 2000). Horvath and Symonds (1991),

for example, found that the alliance had a more robust link to outcome than other

relationship factors, and Stiles, Agnew-Davies, Hardy, Barkham, and Shapiro (1998)

found that all aspects of the therapeutic alliance were positively correlated with

outcome.

Research has tended to focus on which client characteristics impact on the

therapeutic alliance (e.g. Satterfield & Lyddon, 1995; Mallinckrodt, 1991). Horvath

(1994) suggested that pre-therapy variables such as clients’ motivation, social

relationships, and so forth, impact upon both the alliance and outcome. Luborsky

(1994) argued that in part, the positive relationship capacity of the client provides the

foundation for the alliance. Therefore, the capacity to form an alliance is certainly partly

a quality that the client brings to treatment.

However, it has been argued that therapists’ capacity to form relationships is equally

important in alliance formation. Beutler (1997) suggests that these variables should be

given at least as much attention as client factors and therapeutic models in

psychotherapy research. Interest in the factors affecting the therapeutic alliance has

recently begun to broaden to include therapist characteristics. Nevertheless, much of the

research has focused on issues of therapist competence and adherence to treatment

protocol (e.g. Kivlighan, Patton, & Foote, 1998). Furthermore, Elkin (1999) stated that

much of the literature on therapists has been carried out as a secondary factor in

outcome/alliance research. This has meant that often relatively small numbers of

therapists have been studied, and the generalizability of the findings is unclear.

Notwithstanding these limitations, the literature in this area indicates that the personal

qualities of the therapist, and, in particular, the ability to form a warm and supportive

relationship are important factors in the formation of the alliance (e.g. Orlinsky, Grawe, &

Parks, 1994; Roth & Fonagy, 1996).

Attachment theory describes characteristic ways that individuals interact and relate

to others. These secure or insecure attachment styles develop in childhood (Bowlby,

1988) and remain relatively stable in adulthood (Collins, 1996). Secure individuals are

comfortable with closeness and intimacy, and with depending on others and having

others dependent on them. Insecure attachment styles are characterized by either over-

or under-involvement in relationships. The primary features of discomfort with

closeness and need for independence are associated with an avoidant or dismissing

attachment style. Other aspects of insecure attachment styles include the very opposite

features; here individuals show a preoccupation with relationships and a need for

Susanna Black et al.364

approval. Such individuals are described as having an anxious-ambivalent or

preoccupied attachment style.

Bowlby (1988) states that whenever people are frightened, fatigued, or sick they

show attachment behaviours aimed to elicit care-giving behaviours in others. The type

of care-giving offered is dependent on the attachment styles of the both the distressed

person and the ‘caregiver’ (Bowlby, 1988). It could be argued that one of the defining

features of psychotherapy is that it occurs when the client is vulnerable, and therefore

the attachment style of both the client and therapist (as caregiver) is likely to have an

impact upon the formation of the therapeutic relationship. For example, Hardy et al.

(1999) found that client attachment styles were related to differences in therapists’

responses at significant moments in therapy.

Attachment can be measured by self-report or by interview. The adult attachment

interview (AAI; Main & Goldwyn, 1984) is generally thought to be the most accurate

measure of attachment style. However, a number of self-report measures have also been

developed. Some of these measures focus on romantic attachment (Hazan & Shaver,

1987), whilst others focus on attachment in relationships more generally (Bartholomew

& Horowitz, 1991). These behavioural dimensions of attachment styles have been

operationalized in a self-report measure: the Attachment Style Questionnaire (Feeney,

Noller, & Hanrahan, 1994). This questionnaire contains five scales derived from

principal component analysis: Confidence, Preoccupied with relationships, Need for

approval, Relationships as secondary, and Discomfort with closeness. It has been used in

other studies exploring non-romantic attachment style (Danov & Bucci, 2002; Troisi,

D’Argenio, Peracchio, & Petti, 2001).

Relatively little research has examined therapist attachment styles in relation to any

aspect of therapy. Those studies that have been conducted have tended to suggest that

the quality of the therapeutic relationship, issues that arise in therapy, and perceived

competence of the therapist are related to therapists’ attachment styles. At least one

study has found no relationship between counter-transference behaviours, attachment

styles and the therapeutic alliance (Ligiero & Gelso, 2002). Wheeler (2000) found that

personality constructs such as personable/aloof and open/closed (rather than

constructs related to learning, such as intelligent/limited, or to the role as a counsellor,

such as professionally skilled/incompetent) are most frequently used by trainers to

discriminate between good and bad counsellor trainees. A further study which explored

the therapists’ resolution of ruptures in the alliance, and the attachment style of both the

therapist and the client, found that more anxiously attached therapists tended to

respond less empathically, particularly with fearful and secure patients (Rubino, Barker,

Roth, & Fearon, 2000).

In another two studies Tyrell, Dozier, Teague, and Fallot (1999) and Dozier, Cue, and

Barnett (1994) found that there was an interaction between the attachment styles of

clinical case managers and their clients in terms of responsiveness to dependence needs,

client functioning, and the therapeutic relationship. They found that case managers

Attachment, alliance and problems in therapy 365

with secure attachments were more likely to challenge their clients’ internal model of

relationships than case managers with insecure attachments.

Research in related areas also has produced findings suggesting that factors

relating to attachment are important. Henry, Schact, and Strupp (1990) and Henry

and Strupp (1994) found that therapists’ internal representations of past relationships

(introjects) had a strong influence on their session process with clients, and on the

quality of the alliance with at least some clients. Therapists with hostile introjects had

poorer alliances and were more likely to engage in counter-therapeutic or

problematic therapy processes. Dunkle and Friedlander (1996) carried out a study

which looked at experience and personal characteristics of trainee therapists within a

university setting. They found a link between certain personality characteristics of the

therapist, such as comfort with closeness, and the clients’ ratings of the quality of the

alliance. In a review of therapist factors in the alliance, Ackerman and Hilsenroth

(2003) found a positive relationship between a number of therapist attributes and

alliance. These include warmth, openness, flexibility, honesty, trustworthiness,

respectfulness, and so forth. Many of these traits are similar to those used to describe

secure attachment.

Meyer and Pilkonis (2001), in a review of studies of attachment style and its role in

individual psychotherapy, suggested that although secure attachment plays an

important role in the therapist’s skill in handling difficulties in therapy, it is at least

as important for the alliance that the therapist is not anxiously attached. Secure and

avoidant therapists appear to perform better. If not secure, then it appears to be

important to have an opposite attachment style to the client.

The evidence comparing the alliance quality of therapies from different therapeutic

orientation is mixed. Most studies report little differences in alliance ratings across

therapies (e.g. Krunick et al., 1996; Marmar, Gaston, Gallagher, & Thompson, 1989).

A further study, though, did find a difference between therapies (Agnew-Davies, Stiles,

Hardy, Barkham, & Shapiro, 1998), when a more positive alliance was reported for

cognitive behaviour therapy than for psychodynamic-interpersonal therapy by clients,

although not by therapists. Other studies have found differences in the personality style

of therapists of different orientations. Arthur (1999) found that cognitive-behavioural

(CB) therapists tended to be more independent and experience less anxiety, whilst

psychodynamic/analytic (PI) therapists tended to experience more performance

anxiety and neurotic symptoms. Viney (1994) also found differences between therapists

of different orientations in the therapists’ reactions to client expressed emotion.

The aims of this study are to establish the extent to which self-reported attachment

styles of therapists are associated with reported general alliance quality and reported

problems in therapy, over and above their therapeutic orientation. More specifically, our

hypotheses are:

(1) Therapists who report more secure attachment relationships will report having

better general alliances with their clients.


(2) Therapists who report more insecure attachment relationships will report having

more problems in therapy.

(3) Therapists’ attachment behaviours and therapeutic orientation will independently

affect the alliance and reported problems in therapy.

Method

Participants

Questionnaires were distributed to 1,400 psychotherapists who were selected from

three registers of accredited therapists. The lists were published by the United Kingdom

Council for Psychotherapists (UKCP), the British Association of Behavioural and

Cognitive Psychotherapists (BABCP), and the British Confederation of Psychotherapists

(BCP). Therapists working primarily with children and/or families were excluded.

Additionally, some therapists in the London area were excluded due to overlap with

a similar study being conducted there concurrently. All BABCP and BCP therapists who

were not excluded for the above reasons were contacted. From the UKCP listings, one

in three therapists were selected, with either the next or the previous therapist on the

list being selected if the third was excluded.

A total of 491 psychotherapists responded, giving a response rate of 36%;

19 psychotherapists failed to complete either one or both of the major measures within

the questionnaire, resulting in the different sample sizes for different analyses. This was

the expected response rate, but we have no data on non-responders and therefore

cannot say how representative the responders were of the whole sample.

Of the responses, 30% (N ¼ 146) of the psychotherapists were men and 70%

(N ¼ 345) were women. The mode age groupwas 51 þ years and the median was 46 to

50 years. More than half of therapists (54.8%) had over 10 years post-qualification

experience, and only eight therapists had less than 2 years; 79% of therapists had at least

1 year of formal post-qualification training, and 53.8% had more than 3 years formal

post-qualification training.

The therapeutic orientation of the sample was as follows: 34.8% (N ¼ 171) indicated

they were PI therapists; 24.2% (N ¼ 119) were CB therapists; 19.1% (N ¼ 94)

were cognitive-analytic (CAT)/integrative or eclectic therapists; 14.9% (N ¼ 73) were

humanistic therapists, and 6.9% (N ¼ 34) did not specify their orientation.

The therapists had a mixture of core training; 163 were UKCP trained

psychotherapists, 104 had a nursing background, 78 were chartered psychologists,

56 had a core training in social work, 27 were psychiatrists, 22 were accredited by the

British Association of Counsellors (BAC), and 41 were categorized as ‘other’.

Measures

Attachment behaviours were measured using the Attachment Style Questionnaire (ASQ;

Feeney et al., 1994). This is a dimensional questionnaire and was selected because it has

reasonable reliability and validity (Stein, Jacobs, Ferguson, Allen, & Fonagy, 1998).


In addition, it concerns people’s style of interacting in relationships in general, rather

than focusing specifically on romantic attachment.

The ASQ is a 40-item self-report instrument containing five dimensions. The

Confidence scale contains eight items relating to secure attachment behaviours, such as

trust in others and belief in self-worth. There are two scales measuring preoccupied

attachment behaviours: Preoccupation with relationships (8 items) is described as an

anxious reaching out to others in order to fulfil dependency needs, and Need for

approval (7 items) reflects the individual’s need for others’ acceptance and

confirmation. There are also two scales that measure dismissing attachment behaviours:

Relationships as secondary (7 items) contains items which describe the individual as

protecting themselves against hurt and vulnerability by emphasizing achievement and

independence. Discomfort with closeness (10 items) relates to feeling uncomfortable

with intimacy and closeness. Respondents are asked to rate items on a 6-point scale

ranging from totally agree to totally disagree.

In the original study, the scales had good internal and test-retest reliability, and the

items also loaded appropriately on Hazan and Shaver’s (1987) forced-choice attachment

measure. The alpha’s for this sample for the five scales were Confidence

(.78), Discomfort with closeness (.86), Need for approval (.77), Preoccupation with

relationships (.74), and Relationships as secondary (.72).

The therapeutic alliance was measured using the Agnew Relationship Measure

(ARM; Agnew-Davies et al., 1998). It is reported to have good reliability and validity

(Agnew-Davies et al., 1998) and also focuses specifically on the alliance without

reference to therapeutic techniques. There are both therapist and client versions of the

ARM; however, only the therapist form is used here.

The ARM is a self-report 28-item questionnaire. The wording of the questionnaire has

been modified in this study to allow its use as a generalized measure of therapeutic

alliance formation. Given that our survey design might potentially have involved NHS

therapists across a number of health authorities, we sought approval from the UK

Medical Research Ethics Committee (MREC). We were advised that individual consent

would be required for every client in the survey if the therapists completed the alliance

questionnaire with a specific client in mind. Although we disagreed with this advice, we

nevertheless were bound by it and it rendered the original study impossible. We

therefore chose to revise the alliance questionnaire. Respondents were instructed to

think of their clients in general when completing the questionnaire (e.g. ‘I feel warm

and friendly with my clients’, ‘my clients have confidence in me and my techniques’,

‘my clients feel free to express the things that worry them’). This was done for ethical

reasons. Asking therapists to think of any particular client would have meant obtaining

permission from each client. Therapists are asked to rate the items on a 7-point scale

from strongly agree to strongly disagree. The alpha coefficients were re-calculated for

the full questionnaire to ascertain the effect that re-wording had on the internal

consistency reliability of the scale. The alpha for the modified questionnaire was

.84, indicating an acceptable level of internal reliability.


Problems in therapy were measured using the Therapist problem checklist (PCL;

Shroder, personal communication 1999), a measure of therapist-perceived problems.

The scale consists of seven items relating to problems encountered during therapy. The

questionnaire is organized with the following stem: ‘currently, how often do you

feel: : :?’, and the items include ‘lacking in confidence that you can have a beneficial

effect on the client’, and ‘unable to comprehend the essence of a client’s problems’. The

items are rated on a 6-point scale from always to never. High scores on this scale

correspond to more problems in therapy. The internal consistency reliability of this

scale was tested for this sample and was adequate (.79).

General personality features were measured using the Brief Eysenck Personality

Questionnaire (EPQ; Eysenck & Eysenck, 1969), an 8-item version of the full EPQ which

contains four items measuring neuroticism (sample a ¼ :67) and four items measuring

extroversion (sample a ¼ :70).

Results

Therapist-reported attachment styles and reported general therapeutic alliance

Our first hypothesis was that therapists who report more secure attachment

relationships would also report having better alliances with their clients. Correlations

between the variables show a significant positive correlation between the ASQ

Confidence scale and the mean ARM score, r ¼ :441, p , :001, but also significant

negative correlations between mean ARM and the subscales of the ASQ representing

insecure attachment behaviour; ASQ Discomfort with closeness, r ¼ 2:258, p , :001,

ASQ Relationships as secondary, r ¼ 2:182, p , :001, ASQ Need for approval,

r ¼ 2:278, p , :001, and ASQ Preoccupation with relationships, r ¼ 2:315, p , :001.

To test that these associations were not a function of more general personality

variables, and to examine the relative importance of insecure attachment behaviours, we

conducted amultiple regression analysis inwhich two general personality variables (EPQ

extroversion and EPQ neuroticism) were entered first, followed by the five ASQ

dimensions (ASQ Confidence, ASQ Need for approval, ASQ Preoccupation with

relationships, ASQ Discomfort with closeness, and ASQ Relationships as secondary).

EPQ extroversion and EPQ neuroticism explained 9.4% of the variance. This was

significant, adjusted R2 ¼ :090, Fð2; 380Þ ¼ 19:8, p , :001. With the second block the

regression explained 21.3% of the variance, adjusted R2 ¼ :199, which was significant,

Fð7; 375Þ ¼ 14:53, p , :001. The attachment dimensions explained a further 11.9% of

the variance in total alliance score. The R 2 change was tested and was highly significant,

Fð5; 382Þ ¼ 11:34, p , :001. The beta weights suggested that the predictors which

remained significant once all shared variance was removed were ASQ confidence,

b ¼ 5:18, p , :001, and ASQ Preoccupation with relationships, b ¼ 22:01, p , :05.

Neither of the personality variables reached significance in the regression when shared

variance was removed. This supports the hypothesis that self-reported secure

attachment (therapists who report greater confidence in their relationships) would


add significantly to the amount of the variance in total alliance quality explained by

personality measures alone.

In addition to our primary prediction, therapists who scored high on the ASQ

Preoccupation with relationships scale were associated with poorer alliance scores,

suggesting that therapists who reported a dependent attachment style reported having

poorer general therapeutic relationships than those who reported having a more secure

attachment style.

Self-reported therapist attachment style and reported problems in therapy

Our second hypothesis was that therapists who report more insecure attachment

relationships would also report having more problems in therapy. Again, correlations

between the PCL and the four insecure attachment scales from the ASQ show significant

correlations. In all cases, higher insecure scores correlated with higher problems in

therapy, ASQ Preoccupation with relationships, rð464Þ ¼ :322, p , :001, ASQ Need for

approval, rð464Þ ¼ :165, p , :001, ASQ Relationships as secondary, rð463Þ ¼ :165,

p , :001, and ASQ Discomfort with closeness, rð459Þ ¼ :252, p , :001.

To test that these associations were not a function of self-reported more general

personality variables or self-reported lack of secure attachment behaviours, we

conducted a multiple regression analysis in which the same seven variables were

entered into the multiple regression (using method enter) in two blocks (block one,

EPQ variables; block two, ASQ dimensions). EPQ extroversion and EPQ neuroticism

explained 15.8% of the variance in reported problems in therapy in the first block,

which was significant, adjusted R2 ¼ :154, Fð2; 426Þ ¼ 40:06, p , :001. When the five

attachment dimensions were added in the second block, the variables accounted for

23.3% of the variance, multiple R ¼ :483,R2 ¼ :233, adjustedR2 ¼ :220. This regression

was significant, Fð7; 429Þ ¼ 18:29, p , :001. The regression indicated that the

attachment dimensions explained an additional 7.5% of the variance in problems in

therapy over and above the EPQ variables. The R2 change was tested and found to be

highly significant, Fð5; 429Þ ¼ 8:22, p , :001. Examination of the beta weights

indicated that the predictors with the most significance when all shared variance was

removed were ASQ Need for approval, b ¼ 4:83, p , :001, and EPQ neuroticism,

b ¼ 4:38. p ¼ :001. These were both positive relationships meaning that increasing

reported neuroticism and/or need for approval predicted increased reported problems

in therapy. These analyses offer some support to the hypothesis that self-reported

insecure attachment styles explain a significant additional amount of variance in

self-reported problems in therapy over and above personality variables. However, only

one of the four insecure attachment styles, Need for approval, was associated with high

levels of reported problems in therapy. In addition, the general personality scale of

neuroticism remained significantly associated with high levels of reported problems in

therapy.


Therapists’ therapeutic orientation, self-reported general alliance and problems

in therapy

To test our third hypothesis that therapists with different therapeutic orientations will

vary in their alliances with their clients, and in the frequency of problems in therapy that

they report, we conducted two analyses of covariance. Gender was used as a covariate

as there were proportionately more men than women in the CBT group, than in the

other three orientation groups, x2ð3Þ ¼ 13:56, p , :004.

In the first ANOVA we tested for differences in total alliance scores between

orientation groups. The main effect for orientation was significant, Fð3; 390Þ ¼ 12:00,

p , :001. Post hoc t tests using Bonferroni correction indicated that, as predicted, PI

therapists, M ¼ 5:38, SD ¼ 0:50, reported significantly lower alliance scores than

humanistic therapists, M ¼ 5:48, SD ¼ 0:53; tð194Þ ¼ 3:68, p , :001, CBT therapists,

M ¼ 5:51, SD ¼ 0:45; tð243Þ ¼ 25:17, p , :001, and CAT/integrative therapists

M ¼ 5:48, SD ¼ 0:47; tð217Þ ¼ 24:2, p , :001. The other group differences were not

significant.

The second ANOVA was completed to test differences in problems in therapy

between orientation groups. Again, gender was entered as a covariate. The effect of

orientation was significant, Fð3; 439Þ ¼ 4:18, p ¼ :006. Post hoc t tests using Bonferroni

correction showed that psychodynamic/analytic therapists, M ¼ 16:43, SD ¼ 3:66,

reported significantly more problems in therapy than both CBT therapist, M ¼ 15:03,

SD ¼ 3:6; tð273Þ ¼ 2:98, p ¼ :003, and CAT/integrative therapists, M ¼ 15:11,

SD ¼ 3:4; tð249Þ ¼ 2:83, p ¼ :005. No other pairs of groups were significantly different.

Separate effects of therapists’ reported attachment styles and therapeutic

orientation on reported general alliance and problems in therapy

Finally, the hypotheses that therapists’ reported attachment styles and therapeutic

orientation will independently affect the self-reported alliance and reported problems in

therapy were tested via multiple regression analyses.

The attachment dimensions and the therapist orientation dummy variables were

entered into a multiple regression of mean total alliance score (using method enter) in

two blocks (block one, attachment dimensions; block two, orientation group dummy

variables). The first block explained 20.4% of the variance in mean total ARM score,

which was significant, adjusted R2 ¼ :193, Fð3; 358Þ ¼ 18:34, p , :001. When the

orientation dummy variables were added in the second block, the variables accounted

for 24.2% of the variance, adjusted R2 ¼ :23. This regression was significant,

Fð8; 355Þ ¼ 14:20, p , :001. The regression indicated that the orientation variables

explained a further 3.8% of the variance in mean total ARM score over and above

attachment behaviours. The R2 change was tested and was found to be highly

significant, Fð3; 355Þ ¼ 6:01, p ¼ :001. Examination of the beta weights indicated that

the predictors with the most significance when all shared variance was removed were

ASQ confidence, b ¼ 0:37, p , :001, and Psychodynamic or not, b ¼ 20:24, p , :001.


The regression was repeated with the blocks entered in the opposite order, but the

relative variance explained by each block did not change significantly as a result of this.

The results support the hypothesis that reported attachment styles and therapeutic

orientation independently predict reported general alliance score.

The attachment dimensions and the therapist orientation dummy variables were

entered into a multiple regression of mean PCL score (using method enter) in two

blocks (block one, attachment dimensions; block two, orientation group dummy

variables). The first block explained 19.7% of the variance in mean PCL score, which

was significant, multiple R ¼ :44, R2 ¼ :197, adjusted R2 ¼ :19, Fð5; 401Þ ¼ 19:66,

p , :001. When the orientation dummy variables were added in the second block, the

variables accounted for 20.9% of the variance, multiple R ¼ :46, R2 ¼ :209, adjusted

R2 ¼ :19. This regression was significant, Fð8; 398Þ ¼ 13:14, p , :001. However, the

regression indicated that the orientation variables did not explain anything significant

over and above attachment behaviours, R 2 change ¼ .02, ns. Examination of the beta

weights indicated that the predictors with the most significance when all shared

variance was removed were ASQ Need for approval, b ¼ 5:35, p , :001, and

Psychodynamic or not, b ¼ 1:95, p , :05.

The regression was repeated with the blocks entered in the opposite order but the

relative variance explained by each block did not change significantly as a result of this.

However, the regression of first block containing the therapeutic orientation variables

did reach significance, multiple R ¼ :143, R2 ¼ :02, adjusted R2 ¼ :01,

Fð3; 403Þ ¼ 2:80, p ¼ :040. The results do not support the hypothesis that attachment

behaviours and therapeutic orientation independently predict mean PCL score.

Discussion

This study provides some tentative support that therapist characteristics are important

in the formation of the therapeutic alliance and on the therapists’ experiences of

problems in therapy. More specifically, the results indicate that the attachment styles

therapists self-report are significantly associated with their perceived quality of their

overall general therapeutic relationships with clients and reported problems in therapy.

As predicted, therapists who reported more secure attachments also reported having

better therapeutic general alliances with their clients. The results support the findings of

Henry et al. (1990) that therapists’ representations of their early relationships affect

their interactions with clients. Similarly, Peschken and Johnson (1997) found that level

of therapist trust in their clients (arguably a feature of secure attachment) led to an

increase in facilitative attitudes and correlated with client trust in the therapist. Dozier

and Tyrrell (1998) report that secure models of attachment result in an open,

flexible, and non-defensive approach to attachment related issues. This in turn translates

into approaches to others that are open, receptive and collaborative. These

characteristics are likely to facilitate a positive therapeutic alliance.

This study also found that therapists who reported higher levels of insecure

attachment significantly predicted poorer reported general therapeutic alliance.


The finding supports the conclusion of the review by Meyer and Pilkonis (2001) that it is

at least as important not to have anxious attachment as it is to be securely attached. It is

also supported by other findings in attachment and alliance research such as Dozier et al.

(1994) who found that insecure clinicians intervened in more depth with hyper-

activating (anxious) clients, whereas secure therapists intervened in more depth with

deactivating (avoidant) clients. They concluded that insecure therapists intervened in

a way that failed to challenge their clients’ customary interpersonal strategies. Secure

clinicians appeared to be best able to provide clients with experiences that challenge

their working models. It is perhaps these experiences that are likely to result in a more

positive alliance and outcome.

Only some support was found for the hypothesis that self-reported insecure

attachments would predict reporting more problems in therapy: only one of the four

insecure attachment scales of the ASQ, Need for approval, was associated with problems

in therapy. It is possible that therapists who report more problems in therapy may do so

because they have a higher need for approval, and as a result set more perfectionistic

targets (Andersson & Perri, 2000). It is equally possible that those with a high need for

approval encounter more problems in therapy because they are less able to manage

difficulties when they arise. In addition the EPQ neuroticism was also significantly

associated with problems in therapy. This suggests that perhaps it is confidence in

general (rather than confidence in relationships), that is important in determining

problems in therapy.

The finding of differences in alliance and reported problems in therapy for different

therapeutic orientations was interesting. Psychodynamic therapists had the lowest

self-rated alliance score, with CBT therapists having the highest. This reflected previous

research (e.g. Arthur, 1999; Agnew-Davies et al., 1998). A multiple regression showed

that both orientation and attachment behaviours independently predicted a significant

amount of the variance in alliance. ASQ Confidence (linked to secure attachment) and

psychodynamic orientation were significant predictors of the quality of the alliance

once shared variance was removed. Psychodynamic orientation predicted a less positive

alliance.

There are a number of possible explanations for this finding. First, there may be

genuine differences between the orientation groups in the quality of the therapeutic

alliance. It may be that the alliance in psychodynamic therapy is weaker than the alliance

in the other therapies (Raue, Goldfried, & Barkham, 1997). Secondly, the theoretical

models informing the way in which different orientations think about relationships may

result in viewing the therapeutic relationship differently. It is possible that theoretical

orientation resulted in differences in the way in which the questions were reflected on

and answered.

The results showed that psychodynamic therapists also reported the most problems

in therapy, with the other three orientation groups reporting similar levels to each other.

Again, this may be as a consequence of the underlying theoretical models informing

responses to questions about problems in therapy. Psychodynamic therapy tends to


emphasize the client and focus on interpersonal and relationship issues, which could

conceivably make them more aware of or focused upon problems when they exist. It

should be noted that in all cases, the level of problems reported was very low.

There are a number of weaknesses in this study that should be taken into account

when interpreting the findings. First, the data are correlational and all the variables were

collected via the therapists’ own perceptions. Significant associations may, therefore, be

as a result of common method variance. Second, this sample is of experienced

psychotherapists, all of whom have an accredited training in psychotherapy. Therefore,

the findings may not generalize to the normal population of psychotherapists and

counsellors, since this sample is likely to have more training than is normal. Third, the

implications are constrained by the low response rate. A large number of therapists did

not return the questionnaires and a number were returned uncompleted. It was not

possible to gain information about the people who did not respond other than which

organization they belonged to.

Fourth, it is possible that the generalized measure of the alliance used in this study

may be measuring something quite different to the ARM as it was originally used. The

reduction of relationships with all clients down to one ‘average client’ is problematic

because relationships with clients can vary within one therapist. This may result, for

example, rather than measuring the quality of the alliance, in measuring the therapists’

confidence in their ability to form alliances with clients. Future research might wish to

compare responses to the ARM using different wording.

In conclusion, three hypotheses were posed at the start of these this study. The first

was that therapists who report more secure attachment relationships will report having

better alliances with their clients. This hypothesis was supported, and in addition there

was evidence that insecure attachment also negatively influenced alliance. The second

hypothesis that insecure therapists would report more problems in therapy was

supported, but a general measure of neuroticism was also important. Finally, there was

partial support for the third hypothesis that attachment behaviours and therapeutic

orientation would independently predict variance in the alliance and problems in

therapy. This was only true for predictions of the alliance.

Although this study indicates a relationship between self-reported attachment styles

and reported general alliance and problems in therapy, further study is needed to

establish the direction of causality and possible interactions between therapist

attachment and client characteristics. For example, Bernier and Dozier (2002) found

that when therapists and clients were more securely attached, both were more

receptive, and more skilled at providing a corrective emotional experience leading to

positive outcome. More detailed study is necessary, using both interviews and

qualitative methods, with therapist-client dyads, to explore how the attachment style of

both parties is important in the formation of the therapeutic relationship. It may be that

different factors are more or less important in the relationship between particular

clients and therapists.


Acknowledgements

Research conducted in partial fulfilment of a Doctorate in Clinical Psychology degree at the

University of Sheffield. Financial support received from Community Health Sheffield Research and

Development Department.

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Received 8 October 2003; revised version received 3 September 2004


self-reported attachment styles and therapeutic orientation of therapists and their relationship...

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