Attachment in psychological therapy: an exploratory study into patient and therapist attachment patterns and their relationship with early engagement and therapeutic alliance

Abstract

Background. Recent research into attachment theory has suggested it provides a useful framework for understanding the psychological therapeutic process. Clinical application of attachment theory has been a recent development in adult mental health research. Previous studies have focused on patient attachment styles and a systematic review of the literature highlights the limited research that explores both patient and clinician attachment patterns. The reported study aims to explore both patient and therapist attachment and the dyadic interaction on the therapeutic process, and, in particular, how attachment influences the early engagement and development of the therapeutic alliance. Methods. Patient participants and clinician participants completed a self-report measure of attachment prior to commencing a psychological intervention. Early engagement was measured through appointment attendance and independent therapeutic alliance ratings from patients and clinicians were completed after the third appointment. Correlations and regression analysis explored the extent to which patient and clinician attachment predicts early engagement and the therapeutic alliance. Results. Fifty-five patients and 38 clinician’s self-report attachment styles indicate greater security amongst clinicians. Patients presenting to mental health services reported higher levels of anxious and avoidant attachment patterns, which were predictive of greater psychological distress. Patient avoidant attachment was associated with poor engagement and both patient anxiety and avoidance attachment were predictive of therapeutic alliance. No relationship was found between therapist attachment and early engagement or therapeutic alliance, and there were no significant interactions between patient and therapist attachments patterns. Conclusions. Findings from the current study suggest that patient attachment style is predictive of reported psychological distress, early engagement and therapeutic alliance. Applying the principles of attachment theory to clinical practice could therefore provide greater insight into the interpersonal dynamics between patient and therapist and help inform services as to how to improve engagement and alliance with insecure patients. The strengths and weaknesses of the study are discussed, which highlights the need for further research with larger samples to build on the current limited findings.