Adult Attachment Patterns and Individual Psychotherapy: A Review

Although attention has mostly focused on the early relationship between children and their parents, attachment theory is a theory of the lifespan development of close relationships. In contrast to the idea that childhood dependence is ideally replaced by emotional independence in the young adult, Bowlby (1988) asserted that healthy human beings continue to rely on attachment relationships in times of danger, vulnerability, or illness. Attachment is defined as an affectional bond to another person, who is irreplaceable by others although there may be more than one such relationship. Attachment relationships are characterized by a need to maintain proximity, distress upon separation, joy upon reunion, and grief at loss. However, what especially characterizes an attachment relationship in comparison to other close relationships is the use of the attachment figure as a secure base from which to explore the world and as a safe haven to flee to in times of distress (Ainsworth, 1989; Bowlby, 1969/1997).

The tendency to form attachment relationships is thought to be biologically “wired in” because of the survival value it represented in human evolution. A hypothesized attachment behavioural system causes children to become attached to caregivers even if the caregiver does not provide the security and comfort sought for. If the caregiver is unreliable or perhaps even maltreating, the child will adjust and modify its attachment behaviour in order to obtain whatever approximation to security is possible in that particular relationship (Bowlby, 1988; Main, 1995). Attachment figures in infancy are normally parents or parent-like figures, but as development progresses, the most important attachment figures become romantic partners or close friends, and in old age sometimes one's own children (Ainsworth, 1989).

The concept of distinctive patterns of attachment initially arose out of the observational studies by Ainsworth et al. (1978) of infant–mother interaction. In an experimental separation and reunion procedure called the Strange Situation, Ainsworth identified three main patterns in children's ability to use the parent as a secure base for exploration. Children labelled B or secure comfortably use the parent as a secure base when exploring the environment. They miss their parent upon separation, seek contact with the parent upon reunion, and can be comforted by the parent and return to exploration. Children labelled A or insecure-avoidant explore the environment without referring back to the parent. They ignore the parent leaving and returning and are not visibly upset; instead, they turn their attention to toys. Children labelled C or insecure-ambivalent are focused on the parent and seem unable to explore. They are very distressed when the parent leaves, but cannot be comforted by the parent upon reunion, instead they appear angry or passive. Later a fourth category D or insecure-disorganized has been added, but children assigned to this category do not show a similar degree of organized response and are always assigned to one of the three ABC categories as well (Lyons Ruth & Jacobvitz, 1999). For detailed reviews of attachment patterns in infants and their correlates, see e.g. Greenberg (1999), Solomon and George (1999), and Thompson (1999).

Attachment patterns in infancy arise out of parent–child interaction and are regarded as a property of the specific attachment relationship—thus attachment patterns with mother and father can differ (Steele, Steele, & Fonagy, 1996). However, Bowlby believed that attachment patterns increasingly become a property of the individual rather than the relationship. This is due to the gradual formation of mental representations of attachment-related interactions—internal working models—which guide the individual in future attachment interactions (Bowlby, 1973/1998). In agreement with Bowlby's assertion, most theorists of adult attachment claim that attachment patterns in adulthood consist of generalized thoughts, feelings and expectations regulating the way that a given individual engages in close relationships (Rholes & Simpson, 2004). Adult attachment patterns are thought to be relatively stable, because new experience is assimilated to the existing working model, and because the patterns give rise to self-perpetuating interactional behaviours. Thus, a person who has experienced warm and sensitive caregiving will have an open and positive attitude towards close relationships in the future, and this will tend to elicit a positive response from others, thus confirming the positively coloured working model. Conversely, a person who has experienced repeated rejection will look for cues of further rejection, and the guarded behaviour resulting from this expectation can actually serve to elicit the feared rejection and confirm the negatively coloured working model.

The concept of attachment patterns is closely linked to the related measurement methods. In the field of infant attachment, the Strange Situation has been paradigmatic, but in the field of adult attachment, two influential strands of inquiry and measurement have developed in parallel since the 1980's. These two traditions use some of the same concepts, but in different ways and within different research fields, and readers who are not well acquainted with the sometimes subtle differences between operationalizations of adult attachment patterns might easily risk misinterpreting research findings in the area. To enable the reader to better judge the research findings on adult attachment patterns in individual psychotherapy, the different measures of adult attachment that have been applied in psychotherapy research are described in some detail here. For more extensive reviews of the existing measures of adult attachment see e.g. Crowell, Fraley, and Shaver (1999), Crowell and Treboux (1995), Hesse (1999), and Stein, Jacobs, Ferguson, Allen, and Fonagy (1998).

An important impetus for adopting the concept of adult attachment into clinical psychology is the growing number of studies showing a connection between insecure attachment patterns, psychological problems, and psychopathology. Such a connection is predicted by Bowlby's (1973/1998, 1980/1998) writings, which deal extensively with the negative effects of loss or separation from attachment figures in childhood. Bowlby (1988) also described how insecure attachment relationships can lead to defensive exclusion of attachment-related thoughts and feelings and thus make the person more vulnerable to future psychological problems. Insecure attachment patterns can be conceptualized as patterns of information processing and affect regulation that developed to protect the person from attachment-related pain, but may stand in the way of happiness and adjustment in future relationships.

Attachment theory does not consider insecure attachment patterns to be psychopathological. After all, even in low-risk populations roughly half of all children and adults are assigned to one of the insecure attachment patterns (van Ijzendoorn & Bakermans Kranenburg, 1996). Furthermore, insecure attachment patterns are considered realistic adaptations to the caregiving environments in which they arise (Crittenden, 1999). It is only when the strategies inherent in the insecure attachment patterns are later rigidly and inappropriately applied to new contexts that they can be regarded as maladaptive.

Following the development of measures of attachment patterns in adulthood, several studies have explored the relation between adult attachment patterns and a range of psychological disorders and problems. On the most general level the conclusion has been that very few persons with psychological disorders are classified as secure, but that there are few clear-cut connections between diagnostic categories and specific insecure attachment patterns (Crowell et al., 1999, p. 456; Dozier, Stovall, & Albus, 1999). Nearly all existing studies of the relation between adult attachment patterns and psychopathology are correlational, so one must refrain from drawing any conclusions with respect to cause and effect in this relationship until more longitudinal studies are available. Also, since most people with insecure attachment patterns do not develop psychological disorders, insecure attachment patterns are more likely to function as general risk factors rather than sole or specific etiological factors. On the other hand, the fact that most diagnostic groups are heterogeneous with respect to attachment patterns, makes attachment pattern a potentially interesting variable in terms of matching or tailoring general treatment strategies to individual client characteristics (Meyer & Pilkonis, 2002).

Bowlby clearly meant for attachment theory to be of use in clinical work, and as a practicing psychiatrist, he himself applied it to the subject of individual psychotherapy with adults.

In A Secure Base, Bowlby (1988, p. 140) noted that: “In providing his patient with a secure base from which to explore and express his thoughts and feelings the therapist's role is analogous to that of a mother who provides her child with a secure base from which to explore the world”. Since security is believed to be a prerequisite for successful exploration, attachment theory suggests that therapists should strive to build a secure attachment relationship with their clients. However, one must expect that psychotherapy clients, many of whom have a history of difficult relationships, approach psychotherapy with internal working models reflecting these difficulties. Thus, the therapist will have to be aware of and address the beliefs and expectations stemming from prior insecure relationships that stand in the way of establishing a secure working relationship. Whatever the goals of therapy are, part of the therapeutic task will usually consist in changing or supplementing the client's existing working models.

Although couched in a different terminology, the above-mentioned therapeutic implications of attachment theory are not very different from ideas found in many schools of individual psychotherapy, psychodynamically as well as cognitively oriented. Attachment theory is more insistent upon the realistic background of clients' “dysfunctional” working models than most psychodynamic theories and entails a greater explicit emphasis on the therapist–client relationship than most cognitive theories, but generally, it does not in itself suggest radically different forms of therapeutic intervention. The most original contribution of attachment theory to the practice of individual psychotherapy probably lies in the framework it provides for understanding the developmental history and internal dynamics of different forms of relationship difficulties or patterns of attachment. An understanding of attachment theory and research can sensitise the clinician to attachment themes, which are bound to be central when working with relationship difficulties (Slade, 1999).

The attachment patterns of clients can be expected to colour their help-seeking behaviour in therapy, and thus a knowledge of the dynamics of the insecure attachment patterns will help clinicians better understand their clients and might also function as a guide with respect to the choice of intervention strategies.

Furthermore, as demonstrated by the correspondence between AAI classification of parents and Strange Situation classification of their children, adult attachment patterns can be predictive of a person's ability to function as a secure base for another person who feels threatened or vulnerable. Thus, attachment patterns are also relevant to help-giving behaviour, making the therapist's own attachment pattern an important variable in the therapeutic relationship. This theoretical relevance of adult attachment patterns to individual psychotherapy forms the backdrop of an increasing number of empirical studies, which will be reviewed in the remaining part of this article.

The majority of empirical studies on the importance of attachment patterns in individual psychotherapy with adults have dealt with the ways in which client attachment patterns affect the therapeutic process. It has been hypothesized that clients with different attachment patterns will behave differently and will make different use of psychotherapy. This in turn might have predictable effects on the quality of the therapeutic alliance and on how therapists react to clients. Although theoretically just as important, fewer studies have looked into the effect of therapist attachment patterns on the therapeutic process.

Just like the attachment patterns of parents predict their ability to function as a secure base for their children, the attachment patterns of therapists would be expected to predict their ability to establish a secure working relationship with clients. In theory, secure attachment in the therapist is preferable, and one would expect a greater frequency of secure attachment in therapists than in client populations. Partial support for these assumptions is found in an investigation of the attachment patterns of 196 British clinical psychologists assessed with the Hazan and Shaver questionnaire, which found 69.9% to be secure, and found insecure attachment in the therapist to be related to more professional problems (Leiper & Casares, 2000). However, even in therapists classified as secure there will always be variation in degrees of attachment anxiety and attachment avoidance, and such differences in style might also affect the therapeutic process.

Similar to the relationship between client attachment patterns and therapeutic alliance, one might reasonably expect to find a relationship between therapist attachment patterns and alliance. This was investigated by Dunkle and Friedlander (1996), who studied the relation between therapeutic alliance and therapist attachment patterns as measured by the AAS in 73 therapists working in a university setting. They found that comfort with closeness in the therapist was positively related to client ratings of the emotional bond to their therapists. In contrast to this, the previously mentioned study by Sauer et al. (2003) somewhat surprisingly showed that therapist attachment anxiety as measured by Simpson's Adult Attachment Inventory was positively related to client-rated alliance in early therapy. Sauer et al. suggest that the initial good rating of alliance with therapists rated higher on attachment anxiety might be a result of the anxious therapists working harder to make the client feel good about the relationship. However, this is not productive in the long run, and anxious attachment in the therapist was found to have a negative effect on client-rated alliance over time.

Ligiero and Gelso (2002) examined the relationship between alliance as rated by therapists and supervisors and therapist attachment patterns as measured by the RQ in 50 therapists conducting long term psychoanalytic treatment. They found no relationship between therapist attachment patterns and alliance as rated by either the therapists or their supervisors. In combination with the mixed results of Dunkle and Friedlander (1996) and Sauer et al. (2003) on the same issue this suggests that the relationship between therapist attachment patterns and alliance might be less straightforward than the relationship between client attachment patterns and alliance. It could be that the asymmetrical roles of therapist and client imply that therapist personality characteristics are not brought into play to the same extent as client characteristics. The more equivocal findings might also be an effect of therapists being more similar than clients are in terms of attachment patterns, thus making effects of therapist attachment patterns more difficult to detect. However, further studies on the subject are needed before drawing any firm conclusions on the matter.

Rather than focusing on the therapeutic alliance, other studies have dealt with the more direct link between therapist attachment patterns and therapist behaviour in therapy. Based on theory, one would expect secure therapists to show more sensitivity to clients, whereas therapists with insecure attachment patterns might be characterized by varying degrees of countertransferential behaviour originating in their own attachment-related issues. The previously mentioned study by Rubino et al. (2000) evaluated the attachment patterns of the 77 therapists-in-training by the RSQ and examined the relation between therapist attachment patterns and degree of empathy and depth of intervention in response to the simulated rupture episodes. RSQ scores were analyzed in terms avoidance and anxiety (Brennan et al., 1998), and degree of anxiety in the therapist was found to be negatively related to degree of empathy in responding to the rupture episodes. This is understandable, as the more anxious therapists might feel threatened by the rupture and consequently fail to empathize with the client. However, one would also expect therapist avoidance to affect response modes, but no such effects were found.

The above-mentioned study by Ligiero and Gelso (2002) also inquired into the relation between therapist attachment patterns and therapist countertransference behaviours as rated by supervisors. The assessed countertransference behaviours encompassed a number of antitherapeutic therapist behaviours such as rejecting the client, or talking too much in the session. Scores on the three insecure attachment patterns did not predict differences in countertransference behaviour, but there was a significant inverse relation between level of secure attachment in the therapist and negative countertransference behaviours. Even though one would expect scores on the insecure attachment patterns to predict a greater level of countertransference behaviour, the relationship that Ligiero and Gelso did find evidence of is consistent with attachment theory, in that one would expect secure therapists to be more able to refrain from engaging in negative countertransference behaviour.

Finally, the link between therapist attachment patterns and therapist behaviour in treatment was examined by Dozier, Cue, and Barnett (1994), who used the AAI scored with Kobak's Q-sort to evaluate the attachment patterns of 18 case managers working with 27 psychiatric patients. Case managers' descriptions of their interventions with patients were rated by observers for depth of intervention and attention to dependency needs in the patient. The score for depth of intervention distinguished between psychological interventions on one end of the scale and more practical help on the other end. More deactivating case managers were found to intervene in less depth and perceive less dependency needs in the patient, and more hyperactivating case managers were found to intervene in greater depth and perceive greater dependency needs in the patient.

Thus, case managers who scored high on deactivation or hyperactivation of attachment seemed prone to act accordingly. This finding seems to support the idea of countertransferential reactions in therapists who are insecure or lean towards one of the insecure attachment patterns.

Studies of the impact of attachment patterns on the outcome of psychotherapeutic interventions are still quite modest in number and have primarily been concerned with predicting outcome on the basis of client attachment patterns. Client attachment patterns can be relevant to psychotherapy outcome in at least two ways. Firstly, clients with certain attachment patterns might fare better in psychotherapy or in particular forms of psychotherapy than other clients. Secondly, because of the link between insecure attachment patterns and psychological problems, it might be interesting to look at psychotherapy outcome in terms of change in attachment patterns. That is, adult attachment classification might be used as an outcome measure in itself.

Even though research on adult attachment patterns in individual psychotherapy is still in its infancy, the growing numbers of empirical studies clearly support the relevance of adult attachment to psychotherapy process and outcome. The existing studies have linked the attachment patterns of clients and therapists to differences in in-treatment behaviour, to differences in the quality and development of the therapeutic alliance, and to differences in therapeutic outcome. However, the field is marked by a plethora of different measuring instruments and research tactics, which makes it rather difficult to compare studies and extract the essence of the empirical findings so far. Thus, progress in research on adult attachment patterns and psychotherapy is very much dependent on advances in the general field of adult attachment. A greater consensus on the specific meaning of the concept of adult attachment patterns, a greater consensus on relevant measuring instruments and their interrelations, and an increased knowledge of what scores on these instruments predict outside the realm of therapy would be helpful to psychotherapy researchers.

As with other fields within psychotherapy research, clinicians might relevantly ask about the use value of the empirical findings on adult attachment patterns and individual psychotherapy. Here the issue of assessment becomes essential, as clinicians will need quick and reliable assessment of client attachment patterns to be realistically able to consider them in their choice of intervention strategies. Even without formally assessing client attachment patterns, however, a knowledge of what characterizes the different attachment patterns can probably serve as an inspiration to clinicians. Parts of the attachment literature put a lot of emphasis on the merits of attachment security, and the concept of security can obviously be an important guide in clinical work. However, the knowledge that people with secure attachment patterns are easier to treat and benefit more from treatment is not of much use to clinicians when the majority of clients actually have insecure attachment patterns. Thus from a practical viewpoint, future research on adult attachment patterns in individual psychotherapy could profitably inquire more into the challenges of treating people with different insecure attachment patterns, rather than comparing how secure and insecure clients behave and benefit from treatment.