Received: 10 June 2021
Revised: 13 October 2021
Accepted: 11 November 2021
DOI: 10.1002/jcad.12423
RESEARCH ARTICLE
Therapeutic alliance and childhood interpersonal trauma: The
role of attachment, cultural humility, and therapeutic presence
Ramona I. Grad
Department of Psychology and Counseling, The
University of Texas at Tyler, Tyler, Texas, USA
Correspondence
Ramona I. Grad, Department of Psychology and
Counseling, The University of Texas at Tyler, 3900
University Boulevard, Tyler, TX 75799, USA.
Email: rgrad@uttyler.edu
Abstract
This study aimed to assess the role of insecure attachment style, cultural humility,
and therapeutic presence in the development of therapeutic alliance in a sample of
adults with a history of childhood interpersonal trauma (N = 251). Multiple regression analyses indicated that cultural humility, therapeutic presence, and lower levels
of attachment anxiety together accounted for 66.6% of the variance in therapeutic
alliance. Implications for counselors, limitations, and directions for future research
are provided.
KEYWORDS
attachment, childhood interpersonal trauma, therapeutic alliance
Childhood interpersonal trauma (CIT) defined as sexual,
physical, and emotional abuse and neglect occurring before
the age of 18 (Cloitre et al., 2002) is a serious public mental
health problem in the United States. The US Department of
Health and Human Services (2013) found that 678,810 children were victims of childhood abuse in 1 year, and the World
Health Organization (2016) found that approximately one in
four children are physically or sexually abused worldwide.
Freyd (1996) asserted that trauma that occurs in childhood
and in the context of interpersonal relationships can be particularly damaging because of the betrayal involved in the
breach of basic assumptions of interpersonal and social relationships. Moreover, early interpersonal trauma may create
long-lasting psychological and relational dysfunctions, and
it is also connected to a greater probability of experiencing
additional interpersonal trauma during childhood and later in
life (i.e., revictimization; Briere & Scott, 2015). Individuals
that experience one category of interpersonal trauma during
childhood are likely to experience other types of victimization. Multiple types of experiences of interpersonal trauma
referred to as cumulative trauma (Bigras et al., 2017) or
complex CIT (Briere & Scott, 2015) have been reported by
individuals from diverse cultural backgrounds (Pereda et al.,
2014). The accumulation of different forms of CIT is associated with a more severe and complex symptomatology such
as exacerbated psychological and relational distress (Bigras
et al., 2017). Moreover, individuals with CIT history demonstrate interpersonal difficulties that stem from a disturbed
sense of self and others (Godbout et al., 2017), which in turn
influence their capacity to form a strong therapeutic alliance
(TA; Pearlman & Courtois, 2005). Finding safety in relationships can be a challenge for adults with CIT history, and they
often re-enact themes of powerlessness, shame, guilt, distrust,
and abusive and avoidance patterns within the TA (Herman,
1997). A TA with mutual trust is a necessary foundation for
the counseling process (Bordin, 1979); it can facilitate growth
across multiple theoretical and treatment interventions and is
a significant and consistent predictor of treatment outcome
(Flückiger et al., 2018). When the clients have been humiliated, hurt, and betrayed, as often happens with individuals
with CIT history, the process of entering and maintaining a
TA becomes very complex, and it is difficult for clients to
feel safe and trust their counselor.
Very few studies have examined variables that impact TA
in individuals with CIT history. Among the factors that have
been found to contribute to the development of TA, there are
few that received special but separate attention (e.g., attachment style, cultural humility, therapeutic presence). These
constructs are of particular interest because they each have
been found to impact the development of TA, yet they have
not been explored together, nor specifically among clients
with history of CIT.
© 2021 by the American Counseling Association.
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THERAPEUTIC ALLIANCE AND
ATTACHMENT
The construct of attachment, first introduced by John Bowlby
(1969) and further developed by the research of Aisnworth
et al. (1972), characterizes the emotional connection that
infants first experience with their primary caregivers. Attachment theory claims that there are three types of attachment:
secure, and two dimensions of insecure (i.e., anxious, and
avoidant). One of the long-standing debates in the study
of adult attachment is whether individual differences are
best captured using categorical or continuous models of
attachment. The dimensional model describes an individual’s
level of comfort and confidence in close relationships on a
continuum that assesses attachment anxiety and degree of
yearning for intimacy, fear of rejection, and preference for
interpersonal distance on a continuum that assesses attachment avoidance. Mikulincer et al. (2003) have proposed a
model for discussing attachment in categories: secure (low
anxiety, low avoidance), preoccupied (high anxiety, low
avoidance), dismissing (low anxiety, high avoidance), and
avoidant fearful (high anxiety, high avoidance). While there
is a lack of consensus whether attachment is inherently
categorical or dimensional, more recent studies suggest that
individual differences in adult attachment are best conceptualized and measured in a dimensional fashion (Fraley
et al., 2015), and the author chose this conceptualization of
attachment for the current study.
Attachment styles continue into adulthood, with attachment insecurities being overrepresented in adults who have
been neglected, physically or sexually abused during their
childhood (Bakermans-Kranenburg & Van Ilzendoorn, 2009).
Theorists from the analytic school of thought have suggested
that attachment style transfers in the context of TA (Safran
& Muran, 2006), while other theorists (Holmes, 2001) claim
that TA is nothing more than the bond that builds between the
client and the therapist. The influence of attachment style on
TA has been largely studied and the results are inconsistent.
Attachment style was found to account for variance in the TA
(Bernecker et al., 2014), with the avoidant attachment style
negatively impacting TA, and secure attachment style being
associated with higher TA ratings (Diener & Monroe, 2011).
While avoidant attachment was found to correlate negatively
with the TA, Mallinckrodt and Jeong (2015) found that anxious attachment did not significantly correlate with TA. Smith
et al. (2010) concluded that there is no sufficient evidence to
support a significant relationship between attachment dimensions and TA. This conclusion is consistent with results from
recent studies in which researchers did not find significant
relationships between adult insecure attachment dimensions
and TA (Taylor et al., 2015). Moreover, not only there are
empirically based inconsistencies regarding the relationship
between attachment anxiety, attachment avoidance, and
TA, but also there are very few studies to investigate these
constructs in a unique population like CIT survivors. Individuals with CIT history may present long-lasting intimate
and avoidance problems in close relationships (Godbout
et al., 2017) and the CIT experiences may diminish their
capacity to establish a TA. It is recognized that clients with
avoidant attachment tend to consider that the development
of interpersonal relationships is uncomfortable and scary, or
that others are unreliable, which is related to reports of lower
levels of TA (Tasca et al., 2007), as if they are rejecting their
need to form a relationship with their counselor (Smith et al.,
2010). As such, insecure attachment may act as a risk factor
in the capacity of CIT survivors to establish a TA. Therefore,
it appears relevant to study the relationship between TA and
attachment by evaluating if insecure dimensions of attachment (i.e., attachment avoidance and attachment anxiety)
account for variance in TA among clients with CIT history.
Moreover, the potential role of insecure attachment as a
moderator has scarcely been investigated. In the study conducted by Lafrenaye-Dugas et al. (2018), the results suggest
that the interaction between CIT experiences and avoidant
attachment impacts clients’ ability to forge a TA. There is
an apparent gap in the literature concerning the relationship
between attachment styles and the ability to invest in a
strong and satisfying TA in adults with CIT history currently
in counseling. A study examining how clients’ attachment
representations act on the building of a robust TA might
provide guidance toward appropriate therapeutic tools and
the design of tailored interventions for these clients.
THERAPEUTIC ALLIANCE AND
CULTURAL HUMILITY
Cultural context shapes human behavior and an inclusive
clinical approach for counseling individuals who survived
interpersonal trauma should recognize the importance of culture (Brown, 2008). The relationship between trauma and culture is a critical one because traumatic experiences typically
demand a response from the culture in terms of healing, treatment, interventions, counseling, and medical care. In recent
years, there is an increased interest in the mental health field
in moving toward a cultural humility approach in addressing cultural aspects that impact counseling process. Cultural
humility has been defined as the ability to display an otheroriented attitude in regard to diverse cultural identities that
are most salient to the client (Hook et al., 2013). An integral part of cultural humility is how attuned a counselor is
to recognizing power dynamics, which is critical when working with CIT survivors as they often experience, among so
many other feelings, an overwhelming sense of powerlessness. Cultural humility has been described as a way of being
with a client that can facilitate trust and self-disclosure (Hook
et al., 2017). Counselors who are culturally humble not only
strive to be effective but also cultivate a growing awareness
that they are inevitably limited in their knowledge and understanding of a client’s cultural background, which motivates
them to interpersonally attune themselves to the client in a
quest to understand the uniqueness of client’s cultural background and experience (Hook et al., 2013). Engaging clients
with cultural humility can be beneficial to the process and
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outcome of counseling (Davis et al., 2016; Owen et al., 2016).
Specifically, in engaging with clients from different cultural
backgrounds, cultural humility has been linked to developing
a stronger TA (Davis et al., 2016; Mosher et al., 2017) and
achieving higher rates of improvement (Hook et al., 2013).
Research exploring the relationship between cultural
humility and TA has mostly been conducted in college student population, and to the best of author’s knowledge there is
no study to date that specifically investigates the relationship
between cultural humility and TA among individuals with
CIT history. Culture, identity, and social context have largely
been invisible components of conceptualization of working
with trauma survivors (Brown, 2008). Therefore, investigating the role of cultural humility in the development of TA is
critical among individuals with CIT history.
THERAPEUTIC ALLIANCE AND
THERAPEUTIC PRESENCE
Therapeutic presence has been promoted by many professionals regardless of orientation (Wampold, 2007) and it implies
counselor being fully in the moment on several dimensions,
including physical, emotional, cognitive, and relational. Therapeutic presence is viewed as a necessary and preliminary
step to building stronger TA (Hayes & Vinca, 2017). Geller
and Greenberg (2012) concluded that four dimensions are key
to therapeutic presence: (1) the sense of “being grounded,
which includes feeling centered”; (2) the sense of being
immersed “in the moment with the client”; (3) “the sense
of spaciousness or an expansion of awareness”; and (4) the
sense of “intention for presence to be with and for the client’s
healing process” (p. 109). When counselors are fully in the
moment and attuned with their clients, their receptive and safe
presence sends a neurophysiological message to clients that
they are being heard, met, felt, and understood. This process
elicits a reciprocal experience of safety between counselor
and client and strengthens the TA (Geller & Porges, 2014).
In addition to the theoretical support (Colosimo & Pos,
2015; Schneider, 2015), empirical studies support the role of
therapeutic presence in the development of the TA. Geller and
Greenberg’s (2002) model of counselor therapeutic presence
derives from a qualitative study of expert counselors’ experience. Later, Geller et al. (2010) built a 21-item counselor
self-report measure called the Therapeutic Presence Inventory (TPI-T) and a three-item client self-report version (TPIC) for clients to report their experience of their counselor’s
presence. Studies using the TPI measures have suggested that
clients’ perception of therapist presence predicts TA and session outcome (Geller et al., 2010). Further, Pos et al. (2011)
used the TPI-C to explore whether therapeutic presence measured within sessions predicts the TA within those sessions
and the results suggest that presence has a unique influence
on clients’ perception of the TA.
Attachment literature documents that CIT and early lack of
attunement result in emotional dysregulation (van der Kolk,
2005). When clients experience lack of secure attachment
GRAD ET AL.
to their primary caregivers, they can perceive themselves to
be chronically in danger; thus, instilling a sense of safety
through being present with and for clients can downregulate their defenses and promote growth and change. When
counselors relate with their clients as a calming presence,
it activates their social engagement system and over time
this supports clients’ felt sense of safety and regulation in
the therapeutic relationship, which in turn supports clients
to process trauma and engage in therapeutic work (Geller &
Porges, 2014; Gray, 2018). In addition to promoting optimal
engagement between counselor and client, a safe TA has also
the potential to contribute to the repairment of attachment
wounds and provides the space for healthy interactions essential for growth and healing of clients (Allison & Rossouw,
2013). Despite the critical role therapeutic presence has in
developing safety and promoting trauma work, there is a lack
of research investigating the relationship between therapeutic presence and TA among individuals with CIT history. The
author identified no prior empirical study that investigated the
relationship between therapeutic presence and alliance in this
population.
Van Nieuwenhove and Meganck (2017) suggest the importance of investigating the interpersonal difficulties in the
treatment of interpersonal trauma, especially in the formation of the TA. The current study includes variables related
to interpersonal difficulties of CIT survivors (e.g., attachment style, therapeutic presence, and TA), while also including cultural considerations through the inclusion of cultural
humility. Therefore, the purpose of the study is to explore the
relationships among insecure dimensions of attachment (i.e.,
attachment anxiety, attachment avoidance), cultural humility,
therapeutic presence, and TA in a sample of individuals with
CIT history. The study was guided by the following research
questions:
Research Question 1: What are the relationships among
attachment anxiety, attachment avoidance, cultural
humility, therapeutic presence, and TA in individuals
with CIT?
Research Question 2: Do attachment anxiety, attachment
avoidance, cultural humility, and therapeutic presence, serve as predictors of TA in individuals who
experienced CIT?
Research Question 3: Does attachment moderate the
relationship between therapeutic presence and therapeutic alliance in individuals who experienced CIT?
Research Question 4: Does attachment moderate the
relationship between cultural humility and TA in individuals who experienced CIT?
METHOD
Participants
In order to be included in the final sample, participants had to
meet four inclusion criteria: (1) be 18 years of age or older;
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(2) experience of at least one interpersonal traumatic event in
their childhood; (3) currently in counseling for trauma; and
(4) attending at least four individual counseling sessions with
the same mental health professional. Including various categories of mental health services providers is common when
investigating TA (Flückiger et al., 2018) and attitudes and
behaviors displayed by the provider in counseling sessions
(Ivers et al. 2020). The final sample consists of 251 participants after removing 444 of them due to not meeting all
four inclusion criteria (n = 397, 57.12%), the completion
time cut-off score (n = 1, 0.14%) and attention checks cut-off
score (n = 26, 3.74%), and for missing data (n = 20, 2.87%).
Participants’ ages ranged from 18 to 62 (M = 33.06, SD =
9.78), with 77.3% identifying as female (n = 194), 19% (n
= 50) as male, and 2.8% (n = 7) identified as transgender.
The majority of participants identified as White/Caucasian
(70.1%, n = 176), whereas 8.4% (n = 21) identified as Hispanic/Latino, 8% (n = 20) Black/African American, 7.6%
(n = 19) Multiracial, 4% (n = 10) Asian/Pacific Islander,
0.8% (n = 2) Native American, 0.4% (n = 1) Middle Eastern,
0.4% (n = 1.4%) South Asian, and 0.4% (n = 1) identified as
Asian/Indian. The largest represented group was the one consisting of individuals with some college years without having
a degree (32.3%, n = 81) followed by individuals with bachelor degree (22.7%, n = 57), and by individuals with associate degree (16.3%, n = 41). In this sample, 152 participants
reported being in a relationship (60.6%). Participants primarily identified as heterosexual (66.5%, n = 167), no reported
disability (75.7%, n = 190), and with a personal income of
less than $14,999 (27.1%, n = 68). The greatest percentage
of participants reported that this is not their first time seeing a mental health professional (68.5%, n = 172). Out of
all, 122 (48.6%) reported seeing a psychologist, 94 (37.5%)
a licensed professional counselor, 17 (6.8%) a social worker,
13 (5.2%) other, and 5 (2%) were not aware of their qualification. Most participants attended sessions in private practice (n = 144, 57.4%,), while 44 (17.5%) attended outpatient
care, 31 (12.4%) community agency, and 24 (9.6%) a day
clinic.
Measures
Overall lifetime trauma experience
Participants’ exposure to trauma was assessed using a modified version of The Early Trauma Inventory Self Report-Short
Form (ETISR-SF; Bremner et al., 2000). This is a 27-item
inventory designed to assess interpersonal and noninterpersonal traumatic experiences that have occurred before the
age of 18. Each of the items is answered “yes” or “no.”
The ETISR-SF has evidence for adequate to good internal
consistency (Cronbach’s alpha range from 0.70 to 0.87;
Bremner et al., 2011) and good construct validity (based on
the Clinician Administered PTSD Scale, Blake et al., 1995,
r = 0.73). The author added items that describe events of
interpersonal trauma from the Trauma History Screen (THS;
Carlson et al., 2011) to collect more detailed information
about the participants’ exposure to interpersonal trauma.
The new scale included 31 items and participants responded
“yes as a child,” “yes as an adult,” and/or “no” to each
event. Author used the modified version of ETISR-SF as a
screening tool and to operationalize childhood and adulthood
interpersonal and noninterpersonal trauma experiences. Only
participants who identified as experiencing at least one CIT
event were included in the final sample.
Attachment
The Revised Adult Attachment Scale (RAAS; Collins &
Read, 1996) is an 18-item self-report measure that assesses
adult attachment on a 5-point scale (1 = not at all characteristic of me, 5 = very characteristic of me). The RAAS has
three subscales: (a) close, (b) depend, and (c) anxiety. The
close subscale measures the extent to which an individual is
comfortable with closeness and intimacy (e.g., “I find it relatively easy to get close to people”) and includes six items with
three of them being reverse coded (8, 13, and 17). The depend
subscale measures the extent to which an individual feels they
can trust and depend on others (e.g., “I know that people will
be there when I need them”) and includes six items with four
of them being reverse coded (2, 7, 16, and 18). The anxiety
subscale assesses the extent to which an individual is fearful about being abandoned or unloved in relationships (e.g.,
“I often worry that romantic partners don’t really love me”)
and includes six items with none reverse coded. The items on
each subscale have evidence for good internal consistency (α
= 0.80, α = 0.78, and α = 0.85, for close, depend, and anxiety
scales, respectively; Collins & Read, 1996). Test–retest correlations for a 2-month period were 0.68 for close, 0.71 for
depend, and 0.52 for anxiety (in a sample of adult couples;
Collins & Read, 1990). For this study, the close and depend
dimensions were combined to form an overall index of attachment avoidance, and the anxiety dimension was used as an
index of attachment anxiety. Collins and Read (1996) suggested this alternative scoring procedure that has been used
in previous studies (Huang et al., 2017). In the current sample, evidence for good internal consistency was found (α =
0.84 for attachment avoidance and α = 0.88 for attachment
anxiety).
Therapeutic presence
Therapeutic Presence Inventory-Client version (TPI-C;
Geller et al., 2010) has three items: “My therapist’s responses
were really in tune with what I was experiencing in the
moment,” “My therapist was fully there in the moment with
me,” and “My therapist seemed distracted” (reverse coded
item). Each item is presented on a 7-point Likert scale (1 =
not at all, 7 = completely). TPI-C has evidence for good face
validity and reliability demonstrated in a sample of clients (n
= 114) with major depression (α = 0.85, Geller et al., 2010).
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In this study, Cronbach’s alpha was 0.82. In the current
sample, the researcher used the total score.
GRAD ET AL.
that addressed history of mental health treatment, credentials
of the mental health provider, and types of treatment setting
were included.
Cultural humility
The 12-item Cultural Humility Scale (CHS; Hook et al.,
2013) assesses counselor’s cultural humility as perceived by
the client. The CHS has two subscales: positive (e.g., “My
counselor is open to seeing things from my perspective”;
items 1, 2, 4, 5, 7, 9, and 12) and negative (e.g., “My counselor makes assumptions about me”; items 3, 6, 8, 10, and
11). Participants rate each item on a 5-point Likert-type scale
(1 = strongly disagree, 5 = strongly agree). Items on the scale
have suggested high internal consistency, with Cronbach’s
alpha coefficients ranging from 0.86 to 0.93 in different samples (e.g., college students, adults in counseling) (Hook et al.,
2013). The CHS shows relationships with the TA demonstrating evidence of construct validity (Hook et al., 2013). In the
current sample, the researcher used the total score, and the
Cronbach’s alpha coefficient for the full scale was 0.88.
Therapeutic alliance
The Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) is a 36-item questionnaire. Three versions of
the WAI are available: a client version, a therapist version,
and an observer version. The client version of the scale was
used in this study as researchers suggested that the client’s
appraisal of the alliance has the strongest association with the
outcome (Horvath & Symonds, 1991). WAI has three subscales: goals, tasks, and bond, each of which is based on
Bordin’s (1979) multidimensional theoretical conceptualization of the TA. Each WAI subscale is scored on a 7-point
Likert-type scale ranging from 1 (never) to 7 (always), has
12 items, and includes reverse coded items. Task subscale
includes five reverse coded (7, 11, 15, 31, and 33), bond subscale includes three reverse coded (1, 20, and 29), and goal
subscale includes six reverse coded items (3, 9, 10, 12, 27,
and 34). Subscale scores can range from 12 to 84 and are
summed to obtain a total score. Total scores can range from
36 to 252 with higher scores reflecting more positive ratings
of working alliance. Internal consistency estimates of the total
scores were 0.93 and construct validity 0.76 (client version;
Horvath & Greenberg, 1989). In this study, the total score
of the WAI scale was used to operationalize TA. The internal consistency found was 0.96, suggesting the items demonstrated high internal consistency.
Demographic questionnaire
The demographic questionnaire included questions on age,
gender, race/ethnicity, religion/spirituality, sexual orientation,
college student generation status, religion, sexual orientation, ability status, education level, income level, employment status, and relationship status. Additionally, questions
Procedure
An a priori power analysis using G*Power (Version 3.1; Faul
et al., 2009) estimated the sample size needed to conduct
appropriated data analyses (Balkin & Sheperis, 2011). The
recommended sample size based on the power analysis with
a medium effect size (0.15) and a power of 0.8 (Cohen, 1992)
was 85. The statistical procedures included regression and
moderation analyses. General guidelines suggest that at least
200 participants are needed for moderation analyses (Hayes,
2013). The final sample consisted of 251 participants, suggesting adequate power was present.
Data collection took place following approval from a University Institutional Review Board. Data was collected via
Amazon’s Mechanical Turk website. Participants who qualified for this study were paid $0.50 for completing the 15min study. Participants who did not meet the inclusion criteria
received $0.01. Participation was restricted to users who had
an account from the United States. The survey started with an
online informed consent, and those who gave consent were
directed to the four qualification questions. Participants who
met the inclusion criteria first completed a demographic questionnaire, followed by instruments assessing the study variables. By providing informed and voluntary consent, participants indicated that they understood that the research study
focused on CIT history and their experiences in counseling.
Participant names were not collected during the research and
data was kept secure throughout the research process.
Statistical analysis
Following the data collection process, data were transferred
from the Qualtrics survey platform and analyzed using SPSS,
version 25. Data were first cleaned and screened for potential problems (i.e., normality, linearity, homoscedasticity
of residuals, multicollinearity, and missing data). Twenty
participants began the survey but did not complete it past the
demographics section. The researcher conducted a missing
values analysis and the results of Little’s MCAR test suggest
nonsignificant result, (χ2 = 18.108, DF = 10, Sig. = 0.53)
indicating that the data were missing completely at random.
Due to this being a large sample, power not being an issue,
and the assumption of MCAR satisfied, listwise deletion was
determined as a reasonable strategy for the remaining missing
data (Kang, 2013). After removing the 20 cases, missing data
were evaluated again, and there was less than 1% missing
data for two variables (i.e., cultural humility and TA). Due
to the low percentage of missing data, missing values were
replaced with the series mean (Tabachnick & Fidell, 2007).
Univariate values were explored to assess data for normality.
Skewness index values ranged from −0.866 to −0.150 and
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did not exceed the recommended absolute value of 2 (George
& Mallery, 2018) and kurtosis index values did not exceed
7.0 (Curran et al., 1996); therefore, the assumption of normality was met. Multicollinearity was checked by exploring
tolerance and the variance inflation factor (VIF) as well as the
correlation matrix. The preliminary analysis of hierarchical
linear regression yielded tolerance ranging from 0.470 to
1.000, and VIF ranging from 1.000 to 2.128, indicating that
collinearity was not a problem (Field, 2013). Additionally,
linearity was tested using scatterplots, the author checked
correlation coefficients and no predictors were highly correlated (r > 0.85), so it was confirmed that collinearity
was not an issue. Correlation analyses were performed to
address research question one, regression analyses to address
research question two, while research questions three and
four (i.e., moderation effects) were tested using Hayes’s
(2013) PROCESS macro. Tabachnick and Fidell (2013)
suggested steps to use before testing a moderation effect
using the PROCESS macro (Hayes, 2013) with model 1. The
predictor variables were mean centered to minimize concerns
for multicollinearity. An interaction effect between therapeutic presence and attachment style and cultural humility and
attachment style tested the moderating effect of attachment
style between therapeutic presence and TA and cultural
humility and TA, respectively (Baron & Kenny, 1986).
RESULTS
Descriptive characteristics
The largest group of participants reported experiences of only
emotional trauma in childhood (88.8%, n = 223), followed
by those with experiences of only childhood physical trauma
(78.5%, n = 197), and by those with experiences of only
childhood sexual trauma (60.2%, n = 151). Results indicated
that 84.1% of participants (n = 211) had experienced a
combination of emotional, physical, and sexual childhood
trauma. Multiple separate one-way analyses of variance
(ANOVA) were performed to explore mean differences in TA
based on demographic characteristics (gender, race, religion,
income, education level, and relationship status). Significant
mean differences were found in TA and attachment anxiety
levels. Individuals who identified as females reported higher
levels of TA (M = 197.15, SD = 38.62) than those who identified as males (M = 173.58, SD = 33.16). Individuals who
identified as transgender reported higher level of attachment
anxiety (M = 48.00, SD = 7.3) than those who identified as
females (M = 43.00, SD = 9.36) and those who identified as
males (M = 38.22, SD = 9.81).
The researcher calculated means, standard deviations, and
alpha coefficients for each of the variables (i.e., TA, therapeutic presence, cultural humility, attachment avoidance,
and attachment anxiety). The results of these calculations,
as well as correlations between the variables, are presented
in Table 1. The data indicates levels of TA (M = 192.40,
SD = 38.54) that are lower than levels found in other stud-
ies exploring TA in individuals with trauma history (M =
208.74, SD = 29.35; Taylor et al., 2015). The results indicate
levels of attachment anxiety (M = 3.47, SD = 1.12), and
attachment avoidance (M = 3.51, SD = 0.90) consistent with
levels found in literature (attachment anxiety M = 3.14, SD
= 0.96; attachment avoidance M = 2.90, SD = 0.88; Huang
et al., 2017). Cultural humility mean scores (M = 4.08, SD =
0.72) were similar to mean scores found in other studies (M
= 4.02, SD = 0.86; Davis et al., 2016).
Correlation analyses provided answers to the first research
question (i.e., What are the relationships between attachment
anxiety, attachment avoidance, cultural humility, therapeutic
presence, and TA?). Therapeutic presence and cultural humility significantly correlated with TA (r = 0.714, p < 0.01 and
r = 0.785, p < 0.01). Additionally, therapeutic presence significantly correlated with cultural humility (r = 0.725, p <
0.01) and attachment anxiety with attachment avoidance (r
= 0.527, p < 0.01). None of the two subscales of insecure
attachment significantly correlated with TA (p > 0.05).
Regression analyses predicting therapeutic
alliance scores
To answer the second research question (i.e., Do attachment
anxiety, attachment avoidance, cultural humility, and therapeutic presence serve as predictors for TA in those with
CIT?), a multiple regression analysis was performed. Tests
for multicollinearity indicated a very low level of multicollinearity (VIF = 1.395 for attachment anxiety, VIF =
1.393 for attachment avoidance, VIF = 2.128 for cultural
humility, and VIF = 2.124 for therapeutic presence). Results
of the regression analysis provided partial confirmation for
the research hypothesis, as cultural humility, therapeutic presence, attachment anxiety, and attachment avoidance significantly predicted TA F (4, 246) = 123.009, p < 0.001. Cultural
humility (p < 0.001), therapeutic presence (p < 0.001), and
attachment anxiety (p < 0.05) added statistical significance to
the prediction, with cultural humility receiving the strongest
weight (β = 0.554), followed by therapeutic presence (β =
0.311) and attachment anxiety (β = -0.092). However, attachment avoidance did not contribute significantly to the prediction (β = 0.23, p > 0.05). To better understand the contribution of each of the predictor variables for the outcome variable (i.e., TA), a separate stepwise forward multiple regression analysis was conducted. Cultural humility was found to
be a significant predictor of TA (R2 = 0.615, p < 0.001),
and the addition of therapeutic presence and lower levels of
attachment anxiety made the model even stronger. Attachment avoidance did not make a significant contribution to
the regression model. Together cultural humility, therapeutic
presence, and lower levels of attachment anxiety contributed
to a significant regression equation F (3, 247) = 164.389,
p < 0.01, with an R2 = 0.666 (Table 2). The author chose
this model for its high effect size, explaining 66.6% of the
variance in TA scores, while still capturing significant unique
predictors of TA (Cohen, 1992). From this model, the authors
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GRAD ET AL.
TA B L E 1
Descriptive statistics and correlations for study variables
Variable
M
SD
1
1. Attachment anxiety
20.88
6.72
—
2
3
4
2. Attachment avoidance
42.19
9.62
0.527**
—
3. Therapeutic presence
16.89
4.00
−0.023
−0.040
—
4. Cultural humility
49.02
8.69
−0.054
−0.007
0.725**
—
5. Therapeutic alliance
192.40
38.54
−0.117
−0.041
0.714
0.785*
5
—
Note. N = 251.
*p < 0.05.
**p < 0.01.
TA B L E 2
Stepwise regression analysis results for variables accounting for variance in therapeutic alliance
95% CI
Variable
B
LL
UL
SE B
Constant
21.972*
4.896
39.048
8.670
CH
3.477**
3.134
3.820
0.174
β
Step 1
R2
ΔR2
0.615
0.615
0.660
0.045
0.666
0.006
0.785**
Step 2
Constant
20.488*
4.390
36.585
8.173
CH
2.491**
2.021
2.960
0.238
0.562**
TP
2.949**
1.930
3.968
0.517
0.307**
Step 3
Constant
30.930**
12.329
49.532
9.444
CH
2.463**
1.996
2.930
0.237
0.556**
TP
2.975**
1.963
3.987
0.514
0.309**
AA
−0.456*
−0.871
−0.040
0.211
−0.080*
N = 251.
Abbreviations: AA, attachment anxiety; CH, cultural humility; CI, confidence interval; LL, lower limit; TP, therapeutic presence; UL, upper limit.
*p < 0.05.
**p < 0.01.
used unstandardized regression coefficients and determined
that for each 1-point increase in cultural humility, there was
a 2.46-point increase in TA, and for each 1-point increase in
therapeutic presence, there was a 2.97-point increase in TA.
Conversely, for each 1-point increase in attachment anxiety,
there was a 0.45-point decrease in TA.
Attachment as moderator
The researcher conducted moderated regression analyses to
test the last two research questions. Four separate moderation analyses using the PROCESS macro (Hayes, 2013) with
model 1 tested the moderation effect for each combination
of the two moderators (attachment anxiety and attachment
avoidance) and the two predictor variables (therapeutic presence and cultural humility). None of the two dimensions of
attachment style moderated the relationship between therapeutic presence and TA, and cultural humility and TA, as
evidenced by the nonsignificant interaction effect (p > 0.05).
Table 3 provides a summary of the conditional effects of these
moderation analyses.
DISCUSSION
This is the first study to investigate cultural humility, therapeutic presence, and insecure (i.e., anxious and avoidant)
attachment styles and TA among adults with a CIT history. This is particularly important when considering the
already-demonstrated links between each of the independent
variables (cultural humility, therapeutic presence, avoidant
and anxious attachment style) with the development of
TA in the general clinical population. This study aimed
to fill this gap in the literature by exploring the predictive
nature of these variables on TA among individuals with
CIT, attachment style moderating the relationships between
cultural humility and therapeutic presence, respectively, and
TA. Cultural humility and therapeutic presence strongly
correlated with TA and both dimensions of insecure attachment emerged as nonsignificant correlates with TA. Together,
cultural humility, therapeutic presence, and lower attachment
anxiety were the strongest predictors of TA.
The current sample showed levels of anxious and
avoidant attachment consistent with other studies exploring
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JOURNAL OF COUNSELING & DEVELOPMENT
TA B L E 3
moderators
Conditional effects of therapeutic presence and cultural humility on therapeutic alliance with attachment anxiety and attachment avoidance as
95% CI
Moderator
Estimate
SE
t
LL
UL
p
Therapeutic presence
Attachment anxiety
0.0250
0.0660
0.3783
−0.1051
0.1550
0.7055
Attachment avoidance
−0.0320
0.0439
−0.7305
−0.1184
0.0543
0.4658
Attachment anxiety
−0.0075
0.0289
−0.2579
−0.0644
0.0495
0.7967
Attachment avoidance
−0.0019
0.0188
−0.0996
−0.0389
0.0351
0.9208
Cultural humility
Abbreviation: CI, confidence interval.
experiences of individuals with CIT history (LafrenayeDugas et al., 2018). Survivors of CIT may develop schemas
and behaviors that impact the formation and maintenance
of interpersonal relationships across the lifespan (Godbout
et al., 2017). The results of this study suggest that clients that
have experienced CIT are more prone to developing insecure
attachment styles. Moreover, in this study, attachment avoidance and attachment anxiety did not significantly negatively
correlate with TA, a result that is partly consistent with previous studies that found a nonsignificant relationship between
anxious attachment and TA (Mallinckrodt & Jeong, 2015).
This suggests that the relationship between dimensions of
attachment and TA remains unclear. All participants in this
study attended at least four individual counseling sessions,
which could imply that they overcame the first stages in the
development of the TA. The insignificant correlation between
attachment anxiety, attachment avoidance, and TA found in
the current study could suggest that attachment is salient in
the initial stages of counseling and maybe not be as relevant
to alliance development during the middle to latter stages of
treatment. It could also be that the counselors in this study
were effective at developing the TA in the face of anxious and
avoidant attachment styles and those that did not had clients
drop out and were not included in this study. Majority of
participants in this sample (68%, n = 171) reported attending counseling before and 60% (n = 152) reported being
in a committed relationship (i.e., 35.9% reported being married and 24.7% dating one person). Attending counseling and
being involved in romantic relationships might have altered
the levels of their attachment insecurity. Grossmann et al.
(2005) suggest that attachment is relatively stable over long
periods of time yet subject to change. Ongoing relationships
with family members, new romantic relationships, traumatic
life events, and counseling may impact attachment’s progress
over the years. When added to the regression model together
with cultural humility and therapeutic presence, lower levels
of attachment anxiety did make a unique and significant contribution to the model, accounting for 0.6% of the variance in
TA. This may suggest that despite their anxious attachment
style, clients remained committed to seeking treatment.
In this study, therapeutic presence accounted for 4.5% of
the variance in TA. This is the first study that investigates
the relationship between these two constructs in a sample of
CIT survivors and the results are consistent with previous
literature that suggests that client’s perception of counselor’s
presence predicts TA (Geller et al., 2010). When people are
confronted with traumatic events, such as CIT experiences,
the emotional safety, and presence provided by the counselor
may serve as an anchor to the present moment and makes the
therapeutic encounter possible (Allison & Rossouw, 2013).
Cultural humility also significantly correlated with TA and
accounted for 61.5% of the variance in TA when examined
alone. This result is consistent with previous studies (Hook
et al., 2013; Owen et al., 2016; Mosher et al., 2017) where
clients’ ratings of their counselors’ cultural humility have
been positively associated with perceptions of the TA. Results
suggest that communicating to clients, both implicitly and
explicitly, that their cultural identities are seen and validated
in counseling can be a key building block of the TA and
sets the stage for effective therapeutic work. It is within the
counselor’s responsibility to understand and attend to how
a trauma survivor’s cultural identities and social contexts
impact the experience of trauma and the process of recovery
(Brown, 2008).
The high positive correlations between cultural humility,
therapeutic presence, and TA found in this study contribute to
the literature supporting TA as a function of what transpires
in the counseling room. Despite their insecure attachment
style, it appears that clients are not predetermined to fail to
form alliances; this may suggest that it is imperative for the
counselor to account for attachment style, display cultural
humility and therapeutic presence, and nurture the TA in the
counseling process.
Implications for counselors
The majority of participants in this study (88%) reported
cumulative experiences of CIT events, which further supports
the fact that CIT remains an endemic problem. Given the
high prevalence of individuals who report any experience
of CIT, counselors are likely to encounter clients with
trauma history. Therefore, they must take into account how
these early experiences may impact both psychological and
304
interpersonal functioning in order to accurately assess and
provide a treatment that is tailored to survivors’ needs and
capacities. By recognizing the presence of CIT, counselors
will be more able to validate survivor’s trauma history. Moreover, through a safe and genuine therapeutic relationship,
counselors should be able to provide a warm, safe, and
empathic environment that will help survivors in cultivating
a new conception of self and others. Thus, survivors will
experience a sense of hope and a feeling that their traumatic
experience does not define who they are.
The current study adds to the existing literature on the
impact of cultural humility on TA. Addressing client’s cultural background and identifying ways in which culture
impacts client’s healing in session is an important aspect
of working effectively with culturally diverse clients (Owen
et al., 2016). As suggested by the results of this study, this
holds true also among clients with CIT experiences. Mattar
(2010) indicates that while in the field of traumatology there
has been a slow but steady recognition of the importance of
cultural sensitivity in understanding and addressing trauma,
recommendations on how to do this and how to prepare counselors to adopt a culturally sensitive approach to those with
trauma history are limited. Hook et al. (2017) provide a theoretical framework for applying cultural humility in counseling by building the TA. These specific methods may be
applied when working with trauma survivors. For example,
engaging a client with openness, curiosity, and respect may
lead to positive feelings and closeness between the counselor
and the client (i.e., bond) (Hook et al.,2017). The authors also
encourage counselor and client to come together and collaboratively create direction and focus (i.e., goals). Finally, they
mention expressing openness and a desire to understand how
the client views and interacts with the world, which improves
connection and cooperation about what happens in the counseling room (i.e., tasks). In working with individuals with CIT
history, counselor may display a culturally humble attitude
by being alert, searching for ways to connect with and bring
culture into the room, linking cultural issues to the experience of trauma, or using the client’s culture as a source of
support. For example, a counselor might ask with an authentic curiosity about a client’s cultural background and explore
related values, such as the role of family and friends, any
religious/spiritual influences, experience of gender and social
class, and sexual beliefs and norms, and how multiple dimensions of their culture may be linked to their trauma experience. These approaches promote a holistic understanding of
the client, and help respect and receive the client as a whole
human being.
In addition to engaging clients with cultural humility,
counselors may need to develop a conceptual and practical
understanding of therapeutic presence to aid in their effectiveness (Geller et al., 2010). Results of this study suggest
that counselors’ presence as perceived by clients with CIT
history significantly predicts TA. Demonstrating an open
self- and other-awareness, being in the present moment, and
promoting safety are significant not only in enhancing TA but
will also support clients with CIT history in processing their
GRAD ET AL.
trauma and engage in counseling work (Geller & Porges,
2014). Results in this current study support the importance
of counselors using immediacy as a skill to show therapeutic
presence, especially if counselors do not know what is going
on for a client in the moment. Attending to and assessing
client’s emotional and physiological experience (a) allows
counselor to be more aware of client experience; (b) assists
the client to increase awareness of their own experience and
thereby potentially increase their presence; and (c) helps the
client to know the counselor is interested in and aware of their
current experience, thus increasing the sense of feeling seen
and understood (Siegel, 2011). When clients with CIT history
feel seen and understood by their present-centered counselor,
their brain likely establishes a neuroception (evaluation of
risk in the environment; Porges, 2003) of safety and therefore
a stronger TA (Geller & Porges, 2014). By practicing presence inside and outside of sessions, counselors help build the
neural pathways for presence. This in turn will allow them
to be able to use presence intentionally in the session with
clients and increase the ability to sustain presence in session
while also teach clients with CIT that it is safe to be present.
Lastly, illuminating the role of client’s attachment in TA
may have clinical utility. Targeting attachment during counseling may be a strategy for improving TA. Castonguay et al.
(2006) suggest that discussing the TA with clients that have
an anxious attachment style may in time change attachment
patterns by ‘‘[paving] the way for corrective relational experiences’’ (p. 276) which in turn may improve the client’s maladaptive interpersonal schemas. Many individuals with CIT
experiences do not possess the necessary foundation to form
and maintain a stable interpersonal relationship, especially
with others who are reliable, safe, and trustworthy, including
the counselors (Pearlman & Courtois, 2005). Knowing that
the degree to which clients feel cared for, accepted, and safe
in the TA has a significant influence on clients’ willingness to
engage in counseling (Lawson et al., 2017), counselors have
the responsibility to address the fear of rejection that these
individuals experience so that with time, clients develop the
trust and safety that they yearn for. Counselors are encouraged to pay particular attention to the quality of the TA when
working with individuals with a history of anxious attachment. This type of attachment histories could serve as red
flags allowing the counselor to predict the potential for ruptures in the alliance and intervene proactively to minimize
their damaging effects while also maximizing the therapeutic
opportunities inherent in working through them. Counselors
would do well to carefully monitor the relationship for signs
of discontent. When they spot these signs, counselors can use
relationally based interventions to repair the alliance.
Limitations and future directions
Although the present study provides important findings for
counselors, it is not without limitations. This study is crosssectional, and therefore it is impossible to know if the results
accurately represent the causal order of the variables. Since
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JOURNAL OF COUNSELING & DEVELOPMENT
it is accepted that ratings of TA change over time, in future
studies longitudinal, repeated measures of the TA should be
implemented to increase the validity of findings. Another
limitation is that it completely relies upon self-report measures. This may limit credibility of results since participants
may have desire of self-preservation and self-enhancement,
while also they may present with potential issues with selfdeception and memory. Participants in the sample were all
treatment-seeking individuals; thus, it is not possible to generalize these findings to the broader community of CIT survivors. Results are based on ratings that come from participants that remained committed to the counseling process
despite their insecure attachment style. This study did not
include either the participants who are in the early stages
(i.e., less than four sessions in) or those who are not currently in counseling. Therefore, in future studies, the use of
comparison groups is recommended (i.e., participants who
are currently in counseling at the beginning stages, middle
stages, later stages, and those who are no longer in counseling) in order to have a holistic understanding of the factors
that may impact the TA. Lastly, this study examined some of
the counselors’ characteristics (i.e., cultural humility, therapeutic presence) in relation with the alliance, although some
other counselors’ attributes (e.g., attachment style, the extent
of clinical experience and training, personality factors) might
influence the development of a strong alliance. Future studies
are needed to evaluate these variables.
Both dimensions of insecure attachment did not correlate
with TA. These findings are consistent with research on the
association between avoidant and anxious attachment and the
TA as many of the studies did not differentiate between anxious and avoidant attachment. For example, the meta-analysis
that examined attachment and TA in individual counseling
(Deiner & Monroe, 2011) lumped these two types of attachment into the single category: insecure attachment. A replication of the current study is suggested where differentiation
between secure and insecure attachment style would be used
so that it not only would create the opportunity for a comparison group, but it would also allow for a more comprehensive
approach to attachment style with a broader range of dimensions being included.
The most commonly identified advantages of MTurk
are efficiency, cost-effectiveness, diversity, and relative
anonymity, which presumably encourages respondents to
be more candid (Litman et al., 2016). However, disadvantages exist. When comparing MTurk samples restricted to
the United States (as this current sample is) to nationally
representative samples, MTurk workers have lower income,
are more educated, and younger, which demonstrates that
MTurk samples are not representative of the general US
population. Moreover, MTurk workers may seek to please
requestors who are paying for their work and may be dishonest. While critical information can be gained from data
collected through MTurk, future studies would benefit from
addressing some of these limitations through a more diverse
sampling procedure that could reveal findings that are more
comprehensive.
CONCLUSION
While they come from diverse cultural backgrounds, survivors of CIT share common challenges, especially interpersonal problems, as evidenced by the high rates of insecure
attachment styles. In the present study, counselor’s characteristics (i.e., cultural humility and therapeutic presence) and
clients’ anxious attachment style were found to account for
66.6% variance in TA. The results suggest that it may be
important for counselors to develop an interpersonal stance
of cultural humility and therapeutic presence when working
with CIT survivors. Additionally, results suggest the importance of attending to clients’ attachment style and how it
might influence the TA. Addressing these factors may provide an opportunity to strengthen the TA and, in turn, enhance
treatment outcome.
ORCID
Ramona I. Grad
https://orcid.org/0000-0003-4451-7143
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How to cite this article: Grad, R. I. (2022).
Therapeutic alliance and childhood interpersonal
trauma: The role of attachment, cultural humility, and
therapeutic presence. Journal of Counseling &
Development, 100, 296–307.
https://doi.org/10.1002/jcad.12423
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