ABSTRACT Title of Document: CLIENT ATTACHMENT AS A PREDICTOR OF THERAPIST INTERVENTIONS, THE WORKING ALLIANCE, AND THE REAL RELATIONSHIP IN THE INITIAL, MIDDLE, AND FINAL PHASES OF PSYCHOTHERAPY John Lawrence Jackson, Doctor of Philosophy, 2014 Directed By: Professor Clara E. Hill, Ph.D., Department of Psychology This study investigated client attachment style as a predictor of (a) therapist interventions in an early, middle, and late session of psychotherapy; (b) client and therapist post-session ratings of the working alliance over the course of therapy; and (c) client and therapist post-session ratings of the real relationship over the course of therapy. A total of 41 clients and 14 therapists completed measures prior to and throughout open-term courses of psychotherapy ranging from 8 to 106 sessions. Client attachment style was measured using the anxiety and avoidance subscale scores from the Experiences in Close Relationships scale (ECR; Brennan, Clark, & Shaver, 1998). Therapist interventions were coded by trained observers using the Psychotherapy Q-Set (PQS; Jones, 2000). A factor analysis of therapist interventions revealed four factors: Therapist Facilitative Approach (TFA), Therapist Psychodynamic versus Behavioral Interventions (TPB), Therapist Supportive Approach (TSA), and Therapist Process Comments (TPC). Client attachment avoidance was positively associated with Therapist Supportive Approach (TSA), such that therapists were more likely to use directly supportive interventions with clients who endorsed higher levels of attachment avoidance at the outset of therapy. Otherwise, client attachment ratings were not significantly associated to overall levels of therapist interventions or change in therapist interventions over the course of therapy. Neither client attachment anxiety nor avoidance significantly predicted initial levels, mean levels, or patterns of change in client or therapist ratings of the working alliance or the real relationship over the course of psychotherapy. The findings are discussed in the context of findings and methodological differences from other investigations of client attachment, therapist interventions, and client and therapist ratings of the working alliance and the real relationship. Implications for future research and clinical practice are also discussed. CLIENT ATTACHMENT AS A PREDICTOR OF THERAPIST INTERVENTIONS, THE WORKING ALLIANCE, AND THE REAL RELATIONSHIP IN THE INITIAL, MIDDLE, AND FINAL PHASES OF PSYCHOTHERAPY By John Lawrence Jackson Dissertation submitted to the Faculty of the Graduate School of the University of Maryland, College Park, in partial fulfillment of the requirements for the degree of Doctor of Philosophy 2014 Advisory Committee: Professor Clara E. Hill, Ph.D., Chair Professor Jude Cassidy, Ph.D. Professor Emeritus Charles J. Gelso, Ph.D. Professor Mary Ann Hoffman, Ph.D. Professor Jonathon Mohr, Ph.D. © Copyright by John Lawrence Jackson 2014 Acknowledgements I wish to thank my advisor, Clara E. Hill, for her invaluable guidance and patience throughout the process of writing this dissertation. Thank you, Clara, for what became and remains a truly Corrective Relational Experience. I also wish to thank Jon Mohr for the warmth and precision with which he served as a consultant for the statistical procedures used in this study. Finally, I am grateful to the clients and professors with whom I have worked in graduate study, great teachers of psychotherapy one and all. ii Table of Contents Acknowledgements ....................................................................................................... ii Table of Contents ......................................................................................................... iii Chapter 1: Introduction to the Problem ........................................................................ 1 Chapter 2: Literature Review ........................................................................................ 7 Chapter 3: Statement of the Problem ....................................................................... 118 Chapter 4: Method .................................................................................................... 123 Chapter 5: Results .................................................................................................... 147 Chapter 6: Discussion .............................................................................................. 198 References ................................................................................................................. 227 iii Chapter 1: Introduction to the Problem Over the past two decades, scholars from numerous disciplines within and outside the field of psychology have produced a sizeable body of literature on the implications of attachment theory for adult psychotherapy (Obegi & Berant, 2009). The origins of this literature can roughly be traced to John Bowlby’s (1988) chapter on what he believed were the essential therapeutic implications of attachment theory. Bowlby explained that psychotherapy involves a secure base attachment relationship within which the therapist collaborates with the client to explore, understand, and restructure the internal working models that underlie psychopathology and maladaptive relational patterns. Bowlby emphasized the therapeutic relationship as fundamental to a successful therapeutic endeavor, asserting that “unless a therapist can enable his patient to feel some measure of security, therapy cannot even begin” (p. 140). Bowlby noted, however, that the therapeutic relationship and therapeutic process will differ based to a large extent on client attachment patterns at the outset of therapy. Clients who enter therapy with pronounced attachment insecurity are likely to misconstrue the therapist’s attentiveness and empathy, responding with distrust and hostility or a yearning for more care and support than is realistic or advantageous. Bowlby noted that tailoring the therapeutic work to address such reactions is imperative to overcoming what are often substantial challenges to initiating and maintaining a secure base therapeutic relationship. Several scholars (most notably Wallin, 2007 and Holmes, 2001) have provided theoretically and empirically derived recommendations on how to best 1 conduct therapy with clients who exhibit pronounced attachment anxiety and/or avoidance. A review of these works reveals that a majority of the material is devoted to a description of likely relational occurrences in therapy, with a primary focus on client attitudes and behavior, rather than how a therapist may modify interventions when working with clients who present for therapy with different attachment styles. For example, Wallin (2007) asserted that the therapist stands to benefit from an initial assessment of a client’s attachment style and an approach to the therapeutic work that fits this assessment. However, in his respective chapters on therapy with preoccupied, dismissing, and disorganized clients, Wallin’s suggestions for working with each client type are largely indistinguishable. Wallin focused, for example, on the necessity of therapist empathy in successful treatment across all three client types. When distinguishable, suggested interventions appear theoretically rather than empirically based. Wallin indicated that metacommunicative confrontation (speaking in the here-and-now about the therapist’s feelings and thoughts regarding the client) is likely helpful for clients exhibiting a dismissive attachment style, whereas limit setting is likely helpful for clients exhibiting a preoccupied attachment style. He further indicated that clients with preoccupied or unresolved attachment styles stand to benefit from mindfulness practice. Although his insights, suggestions, and clinical anecdotes are highly informative, many of Wallin’s notions do not appear to have been empirically derived, nor have they been examined empirically. At present, psychotherapy and attachment researchers possess minimal information on whether or how therapists intervene differentially in their work with clients who present with different attachment styles. 2 In one empirical attempt to gain access to such valuable information, Hardy et al. (1999) used a qualitative method to examine therapist responsiveness in client- identified helpful events in brief-term psychodynamic-interpersonal psychotherapy. The authors adapted criteria from the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1984) to classify clients as preoccupied, dismissing, or both (preoccupied and dismissing) based on client discourse patterns in transcripts of events. The authors found that therapist interventions in 9 of the 10 events involved providing the client with safety and structure and containing the client’s anxiety. Events were also discussed in terms of “interpersonal distance,” such that therapists also focused either on interventions that served to provide the client with understanding (e.g., reflections of feelings) or challenge and a push for change (e.g. interpretations and directives). Hardy et al. noted that preoccupied clients tended to pull more understanding and psychodynamic-interpersonal interventions from therapists, whereas dismissing clients tended to pull more challenging, cognitive- behavioral interventions from therapists. The authors concluded that therapists responses to clients likely differ based on client attachment style, such that therapists initially work to provide a secure base “holding” environment