Client and therapist attachment styles
and the working alliance
Annily Seymour-Hyde, Katherine Berry
and Alison Harris
University of Manchester
Greater Manchester West Mental Health
Foundation Trust
Background
 Well-established association between therapeutic
alliance and outcome (Horvath et al., 2011).
 Hence search for predictors of alliance, including
both therapist and client characteristics.
 Limited evidence of the role of demographic
factors. Stronger evidence for interpersonal
characteristics (Beutler et al., 1994; Norcross,
2011).
Background
 Attachment theory is an interpersonal theory
which has relevance across the life span (Bowlby,
1980).
 Earlier interpersonal experiences influence
interpersonal functioning and methods of
regulating distress in adulthood via attachment
working models.
 Responsiveness and sensitivity of caregiving
experiences in infancy is hypothesised to be key in
determining security in adulthood relationships.
Bartholomew’s model
Positive
(Low)
Positive
(Low)
MODEL OF SELF
(ANXIETY)
Negative
(High)
SECURE
PREOCCUPIED
High self-worth, believes that others are
responsive, comfortable with autonomy
and in forming close relationships with
others.
A sense of self-worth that is dependent
on gaining the approval and acceptance
of others.
MODEL OF OTHER
(AVOIDANCE)
Negative
(High)
DISMISSING
FEARFUL
Overt positive self-view, denies feelings of
subjective distress and dismisses the
importance of close relationships.
Negative self-view, lack of trust in
others, subsequent apprehension
about close relationships and high
levels of distress.
Background
 Insecure attachment patterns may be adaptive in
the context of sub-optimal earlier environment.
But they are:
- associated with psychopathology in adulthood,
including anxiety and depression (e.g. Williams &
Riskind, 2004).
- have a negative impact on the psychotherapy
process, including willingness to seek help (e.g.
Dozier, 1990), therapeutic alliance (Daniel, 2006)
and outcomes (Schauenburg et al., 2010).
Background
 Modifying client attachment patterns has therefore
been conceptualised as a key goal of therapy (e.g.
Mallinckrodt et al., 2010).
 Bowlby’s (1988) idea of the ‘secure therapeutic
base’ and the ‘corrective emotional’ experience.
 Capacity to care for others and provide a secure
base is likely to be influenced by own attachment
style and there is evidence of transmission of
attachment patterns across generations (van
Ijzendooran, 1995).
Background
 Some evidence suggests that therapist attachment
security influences therapeutic alliance and
outcome, particularly in more complex cases (e.g.
Schauenburg et al., 2010)
 But this isn’t straightforward, as there is evidence
for an interaction effect between therapists’ and
clients’ attachment patterns with ‘mismatches’
being associated with better alliances and
outcomes (e.g. Tyrell et al., 1999; Bruck et al.,
2006).
Aims and hypotheses
 To investigate associations between client and
therapist attachment styles, including interaction
effects in routine mental health therapy services.
 We predicted associations between both client and
therapist secure attachment and better alliance
scores.
 We predicted associations between both client and
therapist insecure attachment and poorer alliance
scores.
 We predicted that a mismatch between client and
therapist attachment scores would be associated
with better alliance scores.
Method
 Participants
- 30 therapist-client dyads.
- Recruited from primary care psychology services
in the North West.
 Measures
- Relationship Questionnaire (Bartholomew &
Horowitz, 1991)
- Working Alliance Inventory (Horvath &
Greenberg, 1989)
- PHQ-9 and GAD-7
Results
Hypothesis: Associations between client attachment
and alliance
Client-rated
Therapist-rated
alliance
alliance
Client secure
.25 (.176)
.12 (.541)
Client fearful
-.17 (.384)
-.05 (.790)
Client
dismissing
Client
preoccupied
-.08 (.678)
-.19 (.32)
-.12 (.518)
-.19 (.315)
Results
Hypothesis: Associations between therapist
attachment and alliance
Client-rated
Therapist-rated
alliance
alliance
Therapist secure -.13 (.494)
-.05 (.796)
Therapist fearful -.17 (.375)
-.07 (.670)
Therapist
dismissing
Therapist
preoccupied
.06 (.744)
.11 (.252)
-.08 (.667)
-.13 (.422)
Results
• Post hoc analysis controlling for influence of
client complexity.
- Therapist fearful attachment was significantly
-
associated with client-rated alliance in more
complex clients (r = -.63, p = .016), but not in low
complex clients (r = .33, p = .207).
Therapist preoccupied attachment was
significantly associated with therapist-related
alliance in more complex clients (r = -.80, p =
.853), but not in low complex groups (r = .14, p =
.583).
Results
Hypothesis: A greater ‘mismatch’ between client and
therapist attachment scores will be associated with
better alliance scores
Preoccupied
match score
Dismissing
match score
Client-rated
alliance
.05 (.778)
Therapist-rated
alliance
.43 (.018)
.41 (.024)
-.10 (.597)
Summary and discussion
 Lack of associations between both client and
therapist attachment and alliance.
 Mixed findings in relation to client attachment and
alliance, particularly insecure attachment types
(Smith et al., 2010).
 Attachment to therapist may be more important
than global attachment style (e.g. Mallinckrodt et
al 2005).
 Mixed findings in relation to therapist attachment
and alliance.
Summary and discussion
 Many studies finding associations between
therapist attachment and alliance sample therapists
in training or relatively inexperienced therapists
(e.g. Dunkle & Friedlander, 1996).
 More experienced therapists may be more selfreflective and use supervision to counteract the
potentially negative influence of their insecure
attachments.
 But insecure therapist attachment styles may have
a negative effect on alliance in more complex
cases (also see Schauenberg et al., 2010).
Summary and discussion
 Another possible explanation for mixed findings
in relation to client and therapist attachment and
alliance is interaction effects.
 Consistent with Tyrell et al’s (1999) research with
case managers, discrepancies in dismissing and
preoccupied attachment were associated with
better alliances.
 Although there were differences between client
and therapist ratings of alliance, highlighting the
importance of considering both.
Clinical and research
implications
 Importance of considering therapist experience
and investigating how therapists can develop and
use knowledge of their own attachments styles in
therapy.
 Importance of considering client complexity and
the possibility that therapist’s own insecurity may
have more influence in complex cases.
 Importance of considering interaction between
therapist and client attachment in clinical work.
Clinical and research
implications
 The potential benefits of mismatching.
 But engagement and working phases of therapy
(e.g. Mallinckrodt, 2000; 2010).
 Importance of assessing alliance from both clients’
and therapists’ perspectives in both clinical
practice and research.
Contact
Katherine.berry@manchester.ac.uk