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The relationship between interpersonal functioning, attachment style, and therapeutic alliance in psychotherapy. The authors review studies that suggest a correlation between interpersonal style, adult attachment, and quality of object relations with the alliance. They also propose that dominance and affiliation could be useful predictor variables. evidence for the importance of these factors in predicting the alliance and suggests that secure attachment is a good predictor of positive alliance, while fearful attachment is a predictor of poor alliance.
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A thesis presented to the faculty of the College of Arts and Sciences of Ohio University
In partial fulfillment of the requirements for the degree Master of Science
Gregory A. Goldman November 2005
This thesis entitled QUALITY OF OBJECT RELATIONS, SECURITY OF ATTACHMENT, AND INTERPERSONAL STYLE AS PREDICTORS OF THE EARLY THERAPEUTIC ALLIANCE
by GREGORY A. GOLDMAN
has been approved for the Department of Psychology and the College of Arts and Sciences by
Timothy Anderson Associate Professor of Psychology
Benjamin M. Ogles Interim Dean, College of Arts and Sciences
Dedication This thesis is dedicated to my parents, who worked to make it possible for me to pursue this and every other endeavor I have chosen; to my brother Erik, who was willing to provide influence and be influenced by me and my “soft science”; to my friends, who helped me enjoy this and everything else I have gone through; and most importantly, to Liz, who chose to love me and be loved by me for life. These have been my true therapeutic alliances.
Acknowledgements I would like to acknowledge the indispensable guidance and tutelage of my advisor, Tim Anderson; my committee members, Ben Ogles and John Garske; Nancy Collins and Brent Mallinckrodt, who were kind enough to humor my requests for information; Kim Lassiter and the CPS clinical staff, who supported and encouraged this work; and finally, Margie Wolfe, Amy Gould, and Jill Well, who literally made this study happen.
List of Figures Figure 1: The Interpersonal Circumplex…………………………………………... 25 Figure 2: Scatterplot of Security of Attachment and Quality of Object Relations… 102 Figure 3: AAS and BORRTI Placed Within the Interpersonal Circumplex………..
Introduction Increased attention has been paid to the role of the therapeutic alliance in psychotherapy as an agent of change. Numerous studies have found a moderate but consistent relationship between the alliance and outcome of psychotherapy (for reviews of this literature, see Horvath & Symonds, 1991, and Martin, Garske, & Davis, 2000). What is the alliance? How does it affect the course of psychotherapy? And most importantly, if it is so important to positive outcome, how does one go about fostering its formation? Following is a broad review of the alliance and its numerous correlates in the area of client pretreatment factors, ultimately leading up to an argument for a correlational study (such as the present study) bringing together some of the best predictors. History of the Alliance Construct The concept of the alliance dates back to Freud (1913/1958) who proposed early in his writings that successful analysis requires, among other things, attachment of the patient to the therapist. Freud later (1937/1962) developed this idea, referring to a collaboration between the therapist and patient, with the unified goal of undermining the patients’ neuroses. Freud’s propositions set in motion numerous debates over the therapeutic relationship, including questions about its nature and significance. The term “therapeutic alliance” was coined by Zetzel (1956), who saw the formation of the alliance as the task of both therapist and patient; and that the lack thereof would preclude maximum benefit of the therapist’s services by the patient. Greenson (1965) later introduced the working alliance, defined as the aspect of the therapeutic relationship
(Kohlenberg, Yeater, & Kohlenberg, 1998; Kohlenberg & Tsai, 2000) and multimodal behavioral therapy (Oejehagen, Berglund, & Hansson, 1997). In fact, a focus on the therapeutic alliance is one of the key elements that define dialectical behavior therapy (Robbins & Koons, 2000). One panel discussion concluded that psychodynamic, cognitive-behavioral, and experiential approaches all emphasize the importance of the alliance; however, it is conceptualized differently in each of these orientations (Gaston, Goldfried, Greenberg, Horvath, et al., 1995). For example, the cognitive-behavioral view of the alliance is often more or less synonymous with compliance, the implication being that it will expedite the process of therapy, whereas more psychodynamic and humanistic orientations tend to view the alliance as an end in itself with therapeutic effects. The alliance appears to be related to outcome regardless of theoretical orientation (Horvath & Symonds, 1991; Martin et al., 2000). The present review will explore a number of the client pretreatment characteristics that have been investigated as possible predictors for the formation and maintenance of a healthy therapeutic alliance. Some of the most pertinent findings are summarized in Table 1. While many of the variables reviewed have been individually shown to represent promising leads in the effort to understand how the alliance works, there is a strong need for research that compares the relative contributions of some of these variables in one design. The present study fills this gap in the research by comparing three variables that are thought to provide promising leads in the understanding of interpersonal factors affecting the alliance.
Table 1 Summary of Selected Studies
Citation Predictor Variable(s) Criterion Variable(s) Relevant Findings Eames & Roth (2000) Attachment style (RSQ) Alliance (client & therapist WAI- at sessions 2, 3, 4,& 5)
Fearful attachment associated with poorer alliance,secure attachment associated with stronger alliance Kivlighan, Patton, &Foote (1998) Adult attachment(AAS) Alliance (clientWAI at session 3) AAS Close &Depend correlated with alliance; AAS accounted for 33% variance in alliance Mallinckrodt, Gantt, & Coble (1995) Alliance (client WAI at session 6 or later), adult attachment (AAS), QOR (BORRTI),self-efficacy (SES)
Client attachment to therapist (CATS)
Secure attachment to therapist correlated with alliance, fearful attachment to therapist negativelycorrelated with alliance, QOR correlated with attachment totherapist, adult attachment not correlated with attachment to therapist Mallinckrodt, Porter, & Kivlighan (2005; re-analysis of Mallinckrodt, Gantt,& Coble, 1995)
Client attachment to therapist (CATS), Alliance (client WAI atsession 6 or later)
QOR (BORRTI) Attachment to therapist & alliance both correlated with QOR Muran, Segal, Samstag, & Crawford (1994)
Interpersonal functioning (IIP- CX), symptomsseverity (MCMI)
Alliance (client WAI at session 3) Friendly and submissive interpersonalproblems correlated with alliance (controlling for symptom severity)
Pretreatment Factors and the Alliance Therapist Variables. Basic personal attributes of the therapist such as empathy, non-possessive warmth, and genuineness have long been suggested to be necessary characteristics for proper alliance formation (e.g., Mitchell, Bozarth, & Krauft, 1977). Early researchers in psychotherapy process and outcome proposed that objectivity, honesty, capacity for relatedness, emotional freedom, security, integrity, humanity, intuitiveness, patience, perceptiveness, empathy, creativity, and imaginativeness were all highly desirable therapist characteristics (Krasner, 1962; Slavson, 1964; Swensen, 1971). A subset of these concepts have since been empirically tested, while most, if not all, remain on a veritable “wish list” of traits to which psychotherapists aspire. Therapists’ perceived expertise, attractiveness, and the extent to which they are regarded by patients as trustable have been found to be associated with the alliance (Horvath & Greenberg, 1994). As one might expect, therapists’ skills in negotiating a positive alliance have been found to correlate with the quality of the alliance (Yeomans et al., 1994). Much of the work in understanding how psychotherapist traits affect the alliance remains to be done. Suggestions of the necessity for such research have been made; for example, Mutén (1991) notes that knowledge of both patient and therapist personality profiles may enable clinicians to better understand and maintain a positive alliance. Miller (1991) suggests that personality traits can help “elucidate the personality of the therapist…its interaction with the personality of the client, and the consequent transference and countertransference phenomena” (p. 432). Similarly, Bishop and Fish
(1999) call for more in-depth investigation of therapist personality characteristics. Regrettably, little of this research exists to date. Patient Variables. Research on patient variables indicates that there may be a variety of pretreatment factors that can influence the formation and maintenance of a positive therapeutic alliance. Severity of impairment at intake is one factor that has received attention in the literature. Much of this research finds the alliance to be negatively correlated with severity of pathology; however, it is not clear that the relationship can be characterized this simply. Level of patient disturbance was found to be negatively associated with the alliance by Eaton, Abeles, and Gutfreund (1988), Gaston, Marmar, Thompson, and Gallagher (1988), Kivlighan and Schmitz (1992), and Luborsky et al. (1993). However, Kokotovic and Tracey (1990) found that the alliance was not related to client presenting concerns, and Raue, Castonguay, and Goldfried (1993) found a negative relationship between alliance and symptom distress within psychodynamic treatment but not cognitive-behavioral therapy. Petry and Bickel (1999) found that the alliance acted as a moderating variable between symptom severity and treatment completion. Horvath (2001) reviewed much of the literature on client factors impacting the strength of the alliance, finding “a convergence of data suggesting that there is an interaction among the therapist’s level of experience, severity of impairment, and quality of alliance” (p. 368). Types of pathology may differ in their influence on the alliance. In a sample of adult survivors of child abuse, Paivio and Patterson (1999) found that severity of childhood trauma and the presence of personality pathology were associated with early alliance difficulties. Two specific types of patient pathologies that
formation of the alliance. Indeed, the climate of therapy is largely determined by the client’s behavior. For example, Alpher, Henry and Strupp (1990) identified poor impulse control and poor judgment as factors that may compromise the interpersonal climate of therapy. Five-Factor Personality Traits. One area that has received a modest amount of attention in alliance research has been patient personality traits. The Five Factor Model, or Big Five (McCrae & Costa, 1987) is a common framework for conceptualizing personality, consisting of the following independent dimensional traits: openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism. This being a major area in personality theory, some of this research literature is summarized below. Miller (1991) discusses implications of each of the five factors in the psychotherapy process. Clients with high levels of extraversion, for example, tend to appear enthusiastic about treatment, and engage in the treatment process without much need for therapist prompting. Miller notes that high extraversion patients may appear to exhibit deceptively strong alliances through their eagerness to participate, but he warns that “they also disclose their thoughts and fantasies to passing acquaintances and strangers” (p. 423). Thus, their eagerness to participate may not be indicative of a strong relationship per say, but rather of a general tendency to self-disclose. Conversely, low extraversion (introverted) clients may pose difficulties in establishing an alliance as well; they are by definition uncomfortable with social contact, and have difficulties in engaging in interpersonal relationships. Accordingly, Miller found that extraversion was positively associated with treatment outcome.
Patient openness may have a positive influence on the alliance. Miller (1991) notes that patients high on openness are more likely to accept interventions and are more engaging to talk with; while patients low on openness appear resistant to interpretations and similar interventions and may be perceived by therapists as less interesting or even frustrating to treat. Miller did not find an effect on treatment outcome for openness; however, Keijsers, Schaap, and Hoogduin (2000) found an association between patient openness and outcome, and Svartberg (1993) asserts that openness and the alliance are the two most consistent predictors of outcome. Miller’s (1991) predictions about openness and the alliance have yet to be empirically tested. Agreeableness is also hypothesized to affect formation of the alliance. Miller (1991) notes that highly agreeable patients are exceedingly willing to form an alliance, while less agreeable clients are skeptical and slow to develop an alliance. Similarly, highly conscientious clients are likely to engage in the treatment process with resolve and determination, while patients low on conscientiousness tend to be resistant to treatment, and may be especially low on the task component of the alliance. Miller did find a correlation between conscientiousness and treatment outcome. Neuroticism has been found to be negatively associated with treatment outcome (Miller, 1991; Ogrodniczuk, Piper, Joyce, McCallum, & Rosie, 2003), and Miller (1991) found that neuroticism was positively associated with severity of pathology, especially in the case of borderline pathology. As discussed above, level of severity is often negatively associated with the alliance, especially with regard to borderline pathology (Gaston et al., 1988; Gunderson et al., 1997; Horvath, 2001; Horwitz et al., 1996;
