therapists' attachment, patients' interpersonal problems and alliance ...

Psychotherapy Theory, Research, Practice, Training 2009, Vol. 46, No. 3, 277–290

© 2009 American Psychological Association 0033-3204/09/$12.00 DOI: 10.1037/a0016913

THERAPISTS’ ATTACHMENT, PATIENTS’ INTERPERSONAL PROBLEMS AND ALLIANCE DEVELOPMENT OVER TIME IN INPATIENT PSYCHOTHERAPY ULRIKE DINGER

MICHA STRACK

University of Heidelberg

University of Goettingen

TILMANN SACHSSE AND HENNING SCHAUENBURG University of Heidelberg

The focus of this study is the investigation of the relation between patients’ interpersonal problems, therapists’ attachment representations, and the development of the therapeutic alliance over time. The authors investigated weekly alliance ratings of 281 psychotherapy inpatients, treated by 12 psychotherapists. Alliance quality was measured with the Inpatient Experience Scale. Multilevel regression models showed that patients’ interpersonal problems were associated with the level of alliance quality. Therapists’ attachment security was not related to alliance development, but higher attachment preoccupation of therapists was associated with lower levels of alliance quality. In addition, an interaction effect between therapists’ degree of attachment preoccupation and patients’ interpersonal problems explained variaUlrike Dinger, Clinic for Psychosomatic and General Clinical Medicine, University of Heidelberg; Micha Strack, Georg-August Mueller Institute of Psychology, University of Goettingen; Tilmann Sachsse and Henning Schauenburg, Clinic for Psychosomatic and General Clinical Medicine, University of Heidelberg. We thank Dr. A. Buchheim for the AAI coding, K. Brenk for conducting the attachment interviews, and J. C. Ehrenthal for helpful comments on earlier drafts of this paper. Correspondence concerning this article should be addressed to Ulrike Dinger, Clinic for Psychosomatic and General Clinical Medicine, University of Heidelberg, Thibautstr. 2, D-69115 Heidelberg, Germany. E-mail: [email protected]

tions of the alliance development curve over time. Limitations of the study are discussed. Keywords: therapeutic alliance, attachment theory, interpersonal theory, therapist factors The therapeutic alliance is one of the most intensely studied process factors and its moderate relation to therapy outcome has been demonstrated in numerous studies. It is usually conceptualized as consisting of three main components: the bond between therapist and patient, the agreement on therapeutic goals and on tasks (Bordin, 1979). Although most researchers have studied alliance as a predictor for outcome (e.g., Martin, Garske, & Davis, 2000; Horvath & Bedi, 2002), some studies used alliance ratings as dependent variables and tried to identify client and therapist variables related to it (e.g., Ackerman & Hilsenroth, 2003; Constantino, Arnow, Blasey, & Agras, 2005). Both approaches are important and have contributed to our understanding of the therapeutic process. Alliance Development in Psychotherapy The quality of the alliance is unlikely to stay constant over the whole period of treatment. Based on a proposition by Gelso and Carter (1994), a number of researchers have attempted to model alliance development over time (De Roten et al., 2004; Kivlighan & Shaughnessy, 1995, 2000; Kramer, de Roten, Beretta, Michel, & Despland, 2008; Stiles et al., 2004). Several patterns of alliance development have been described: in very brief treatments with four sessions, patients

277

Dinger, Strack, Sachsse, and Schauenburg with stable alliances could be differentiated from patients with linear and quadratic, that is, U-shaped growth (De Roten et al., 2004; Kivlighan & Shaughnessy, 2000). Stiles et al. (2004) replicated the finding of a stable alliance and a linear growth alliance group for longer treatments (8 and 16 sessions), and found two additional groups (“rapid early improvement” and “deterioration of an initially high alliance”), but had no clear indication of U-shaped alliance profiles. Kramer et al. (2008) differentiated an increasing from a stable and a decreasing group in a university consultation setting. Dinger and Schauenburg (2008) described alliance development in the context of inpatient psychotherapy. They used a regression model with three parameters (alliance level during the middle phase, curve during beginning and termination phase) developed by Schauenburg, Sammet, and Strack (2001) to model alliance development compatible to therapy phases. The most common pattern (22.5% patients) was characterized by early improvement, but a substantial number of patients either had stable alliances (17.2%), improvement only toward the end (14.4%) and U-shaped patterns (11.2%). The relation between alliance development and outcome has also been investigated. Linear growth as well as U-shaped profiles in very brief treatments have been related to favorable outcomes (De Roten et al., 2004; Kivlighan & Shaughnessy, 2000). However, Stiles et al. (2004) reported no association between overall shape of alliance development and outcome of outpatient psychotherapy. In the study by Dinger and Schauenburg (2008), the inpatient group with alliance improvement in the beginning and in the termination part of therapy had the best outcome, while inpatients with initially stable alliances that deteriorated toward the end profited least from psychotherapy. In summary, an association between alliance development and therapy outcome has been demonstrated, although the results appear to be somewhat inconsistent. As alliance develops within an interpersonal context, the question arises, which patient and therapist characteristics are associated with different forms of alliance courses. Patient characteristics that have been related to alliance development include treatment preference in randomized clinical trials (Iacoviello et al., 2007), and treatment expectations and interpersonal problems (Gibbons et al., 2003). Little is known, however, about the influ-

278

ence of therapists’ characteristics on alliance development over time. Based on research with single-point assessments of alliance (Daniel, 2006; Dinger, Strack, Leichsenring, & Schauenburg, 2007; Schauenburg et al., in press), the present study concentrates on patients’ interpersonal problems and therapists’ attachment representations, which are both assumed to influence alliance development over time. Interpersonal problems can be conceptualized in the so-called interpersonal circle around the dimensions affiliation (friendliness— hostility) and control (dominance—submissiveness; Kiesler, 1983; Leary, 1957). Patients’ pretreatment interpersonal problems have been related to alliance quality in several studies investigating different therapeutic settings and forms of therapy. The degree, that is, the overall level of interpersonal problems has been shown to go along with difficulties in treatment and lower alliance qualities (Constatino et al., 2005; Gibbons et al., 2003; Puschner, Bauer, Horowitz, & Kordy, 2005). In addition, the role of specific interpersonal styles has been studied. Most studies reported associations between patient affiliation and alliance quality, either by demonstrating beneficial effects of problems with being “too friendly,” or by showing detrimental influences of being “too cold” (Beretta et al., 2005; Hersoug, Monsen, Havik, & Høglend, 2002; Johansson & Eklund, 2006; Muran, Segal, Samstag, & Crawford, 1994; Paivio & Bahr, 1998; Saunders, 2001). Findings regarding the control dimension are more diverse: few studies reported positive influences of submissiveness (Muran et al., 2005), whereas most studies find no correlation between dominance and higher alliance quality (Dinger, Strack, Leichsenring, & Schauenburg, 2007; Hersoug et al., 2002). Kiesler and Watkins (1989) showed that the influence of patient affiliation and control interacted with therapists’ interpersonal dispositions: The best alliances were observed for patient-therapist dyads with similar degrees of affiliation and complementary control. However, most of the previous studies have related interpersonal problems to single-point assessments of alliance. Less is known about the influence of patients’ interpersonal problems on alliance development over time. Gibbons et al. (2003) found no indications for an influence of interpersonal problems on alliance growth, and Puschner et al. (2005) reported an association of interpersonal problems with alliance only for T1

Special Section: Therapists’ Attachment (beginning), but not for T2 (end of therapy). These findings leave room for further research. In addition to patients’ interpersonal problems, therapists’ attachment representations will be investigated in this study. Bowlby’s attachment theory proposes that not only protection seeking, but also caregiving behavior is influenced by attachment representations (Bowlby, 1988). According to Main, Goldwyn, and Hesse (1985), adults can be classified into four attachment categories: secure-autonomous, insecurepreoccupied, insecure-dismissing, and unresolved. Secure-autonomously attached individuals value close relationships. As caregivers, they are able to adapt their behavior toward the needs of others. In contrast to the secure category stand two insecure groups: insecurepreoccupied and insecure-dismissive. Insecurepreoccupied individuals show a high desire for closeness in intimate relationships. They typically display hyperactivating attachment strategies in emotionally significant relationships, which include a strong approach orientation, attempts to elicit their partners’ involvement through clinging and controlling responses, and efforts to minimize distance to others (Mikulincer, Shaver, & Pereg, 2003). Insecuredismissive persons on the other hand tend to devalue attachment issues and feel more comfortable in distant relationships. They may describe idealized past relationships with attachment figures, but are often unable to describe vivid examples of attachment related situations. Their efforts to keep relationships at distant are often called deactivating attachment strategies (Mikulincer et al., 2003). In addition, a fourth category (“unresolved”) describes individuals with traumatic experiences that have not been integrated adequately. The influence of therapist attachment on the development of the therapeutic alliance has been investigated by Sauer, Lopez, and Gormley (2003). They assessed the quality of the working alliance after the 1st, 4th, and 7th session in a naturalistic outpatient setting. Attachment orientations of 13 therapists and 17 clients were related to the formation of the early working alliance. In their study, therapist attachment anxiety was associated with initially positive alliance ratings, which subsequently dropped over time, resulting in significantly lower alliance levels in later sessions. No other therapist or client attach-

ment variables had significant influences on alliance ratings. This study attempts to replicate and extend the findings from Sauer et al. (2003) in the context of inpatient psychotherapy. In addition to the ambulant outpatient setting, the German medical system also allows inpatient psychotherapeutic treatment of severely impaired patients who are believed to profit better from a highly structured hospital setting. Contrary to the dyadic outpatient setting, the multimodal inpatient treatment includes several therapeutic elements from individual therapy to treatments in a group setting. This results in a greater number of factors that may account for patient change. Consequently, the extent to which an individual psychotherapist influences the outcome of inpatient psychotherapy is smaller compared to outpatient therapy. However, individual therapists vary considerably in the quality of alliance they establish with their patients (Dinger, Strack, Leichsenring, Wilmers & Schauenburg, 2008). Although the inpatient treatment differs in many aspects from outpatient therapy, it seems likely that the dynamics underlying the therapeutic relationship between individual therapist and patient are relatively similar. In addition to the context of psychotherapy, two more factors will be varied in the present study. Unlike the scheduled assessment time points in the study by Sauer et al. (2003), patients in this study evaluated the therapeutic alliance to their individual therapist on a weekly basis (mean treatment duration was 12 weeks), which enabled us to model alliance development in a multilevel regression model similar to the approach chosen by Stiles et al. (2004) and Kramer et al. (2008). The second difference concerns the assessment of therapists’ attachment representations: while Sauer et al. (2003) assessed the attachment orientations of therapists via self-report, our study used expert-rated interviews. This seems especially relevant, as there is an ongoing discussion about the different aspects of attachment that are assessed by self-reports versus observer-ratings (Waters, Crowell, Elliott, Corcoran, & Treboux, 2002). Both traditions have achieved meaningful results in previous studies. However, the studies on the transgenerational passing of attachment (e.g., Fonagy, Steele, & Steele, 1991) as well as the data on longitudinal intrapsychic stability (Grossmann, Grossmann, & Waters, 2005) stem mostly from expert-rated assessment. Therefore, the Adult Attachment Interview (George, Kaplan,

279

Dinger, Strack, Sachsse, and Schauenburg & Main, 1996; Main et al., 2002), which is considered the “gold standard” for assessment of adult attachment, was used in this study. Aims of the Study This study was designed to investigate alliance development in inpatient psychotherapy. It is tested whether patients’ interpersonal problems, therapists’ attachment representations or interactions between patient and therapist dispositions account for variability in alliance ratings over time. Based on previous research on interpersonal problems, we expected a positive association between patient affiliation and alliance level, as well as a negative correlation of the overall degree of interpersonal distress with alliance level. Because of the lack of previous research, we had no specific predictions about the influence of patients’ interpersonal problems on alliance development over time. Based on Sauer et al.’s (2003) findings we anticipated variability in alliance development between therapists and expected to explain some of theses variations by therapists’ attachment representations. We expected a positive influence of preoccupied attachment on early alliance development, but assumed that this positive start would decline over time, resulting in an overall lower alliance quality of therapists with insecure-preoccupied attachment in comparison to patients treated by other therapists. Method Participants The present therapist and patient sample is drawn from a larger study on therapist influences in inpatient psychotherapy (Schauenburg et al., in press). This larger study investigated the influence of attachment representations of 31 therapists on outcome and retrospective alliance ratings. Patients. Patients were included if they were treated by one of the 12 therapists in the participating university clinic, had no change of their individual therapist over the course of treatment and had less than four missings of their weekly alliance questionnaires. The ICD-10 diagnoses of the resulting 281 patients are typical for a German inpatient psychotherapy population, which is characterized by severe impairment and high comorbidities. The most common clinical ICD-10 diagnoses were depressive disorders (57.6%), followed by anxiety (22.1%), eating (18.2%), and

280

somatoform disorders (16.4%). Less frequent were adjustment/stress (8.9%) and obsessive– compulsive disorders (5.0%). A substantial percentage (20.6%) had an additional personality disorder. Their symptom load was high at intake (GSI of the SCL-90 –R M ⫽ 1.39, SD ⫽ 0.60; Franke, 1995). Two thirds of patients were female (69.3%), and their ages ranged from 18 to 70 years (M ⫽ 32.8, SD ⫽ 11.93). Patients gave informed consent for their routinely assessed data to be used in research projects, and the study was approved by the local ethics committee. Therapists. We studied attachment classifications of 12 psychotherapists who treated 281 inpatients at a psychotherapy unit of a German university hospital. The present sample was selected because weekly alliance evaluations existed only in one of the two clinics where the larger study on therapist effects was conducted (Schauenburg et al., in press). All participating therapists from the university clinic (with weekly evaluations of alliance) were included in this study. Therapists from both clinics did not differ with respect to age, professional background, and theoretical orientation. However, the subsample studied here included more female therapists than the therapist sample from the nonuniversity clinic (␹2 ⫽ 5.6; p ⬍ .02). Therapists mostly had a medical background (nine physicians, three clinical psychologists). They were mostly female (nine women, three men), between 26 and 43 years old (M ⫽ 35.7), and their professional experience as psychotherapists ranged from 1 month to 7.2 years (M ⫽ 3.5 years). Half of them (six therapists) were still in postgraduate clinical training. Their therapeutic orientation was mostly psychodynamic: six therapists were trained as psychodynamic, four as psychoanalytic therapists. Two therapists with different theoretical backgrounds (one client-centered and one systemic therapist) described themselves as “very strongly influenced by psychoanalytic/ psychodynamic concepts.” Therapists’ were asked for participation based on their caseload (between 6 and 45 patients; M ⫽ 23.4) and received a monetary reward. Setting All patients were treated within the same multimodal inpatient psychotherapy setting in a German university hospital. The main orientation of the clinic is psychodynamic, but behavioral and

Special Section: Therapists’ Attachment disorder-specific interventions are included in the treatment. Patients were assigned to therapists by an administrative secretary according to therapists’ caseload, and neither therapists nor patients influenced this routine assignment procedure. Patients met with their individual therapist 1–2 times a week, received additional psychodynamic group therapy twice a week, as well as art and body-oriented therapy, and structured daily interactions with highly qualified nurses on the ward. The individual therapist coordinated the additional therapeutic components and was meant to be the primary contact person for patients. The mean treatment duration was 12.0 weeks (SD ⫽ 2.97). Measures Alliance: Inpatient Experience Scale. Patients evaluated the alliance to their individual therapist with the Alliance Scale of the Inpatient Experience Scale (German: “Stationserfahrungsbogen”; Sammet & Schauenburg, 1999) on a weekly basis. The Inpatient Experience Scale (IES) was developed to capture relevant aspects of the therapeutic process in inpatient therapy from the patients’ perspective. It consists of 38 items that form seven scales that demonstrated satisfying to good internal consistencies (Cronbach’s alpha between .71 and .85). For the present study, only the scale “alliance with individual therapist” was used, which focuses mainly on the bond aspect of the therapeutic alliance. The scale assesses emotional closeness and the feeling of being understood as well as agreement on therapeutic goals (“It was easy for me to get close to my individual therapist”; “I felt that I could depend on my individual therapist”; translations by U.D.). Patients are asked to rate the alliance regarding the past week. The four items for the IES alliance scale are answered on a 6-point Likert scale (Cronbach’s alpha ⫽ .71). The items were developed on the basis of the German version of Luborsky’s Helping Alliance Questionnaire (Bassler, Potratz, & Krauthauser, 1995) and chosen to represent mainly Luborsky’s Type I characteristics, that is, the patient experiencing the therapist as providing help that is needed (Luborsky, 1984). The overall mean evaluation of the alliance was positive in this sample (M ⫽ 4.7, SD ⫽ 1.02). Patients’ interpersonal problems. Patients’ interpersonal difficulties were assessed with the

German version of the Inventory of Interpersonal Problems (IIP) before therapy. The German IIP version (Horowitz, Strau␤, & Kordy, 2000) consists of 64 items that are answered on a 5-point scale. Affiliation and control scores were computed with ipsative IIP scales as suggested by the authors. The psychometric quality of the scale has been established for the original version (e.g., Alden, Wiggins, & Pincus, 1990) as well as for the German translation (e.g., Braehler, Horowitz, Kordy, Schuhmacher, & Strauss, 1999). Several validation studies showed that the IIP is able to differentiate between separate clinical groups, has prognostic value in different forms of psychotherapy and is able to relate interpersonal problems to other clinical characteristics (Horowitz et al., 2000). For the present study, the IIP total score was used as measure for interpersonal distress and affiliation and control scores gave indication for specific interpersonal styles. Reflecting the nonsystematic assignment of patients to therapists, a MANOVA revealed no pretreatment differences of patients groups treated by therapists with regard to IIP total, affiliation and control scores (F(33, 807) ⫽ 0.84; p ⫽ .73). Adult Attachment Interview. Therapists’ attachment representations were classified with the Adult Attachment Interview (AII) (George et al., 1996). The AAI is a 1-hr semistructured interview with 18 questions about childhood experiences with primary attachment figures. The intensive rater training ensures high reliabilities; interrater as well as test-retest reliabilities are excellent (Bakermans-Kranenburg & van Ijzendoorn, 1993). The interviewer in this study was an experienced psychologist and specifically trained in conducting AAI interviews. The interview transcripts were coded by an experienced and certified AAI coder. The coding takes into account coherence, flexibility, and completeness of the narrative discourse. The resulting AAI categories are secure/autonomous (F), insecure/ dismissing (Ds), insecure/preoccupied (E), and unresolved (Main et al., 2002). In addition to the assignment of categorical groups, the AAI contains scores on continuous scales (“experience” and “state of mind”). In line with recent work by attachment researchers questioning the use of categorical variables (Fraley & Spieker, 2003), a new method that allows the computation of two continuous measures (“security-versus-insecurity” and “dismissiveversus-preoccupied”) from the AAI state of mind scales was developed (Waters, Treboux, Fyffe,

281

Dinger, Strack, Sachsse, and Schauenburg Crowell, & Corcoran, 2005). Discriminant coefficients for the AAI scales are provided: the securityversus-insecurity dimension comprises five AAI state of mind scales; the highest discrimination coefficient is for “coherence of transcript.” The dismissive-versus-preoccupied dimension comprises seven AAI state of mind scales, and the highest discrimination coefficients is for (inverse) “passivity” and “idealization of mother.” Raw discrimination coefficients were used in this study, allowing a better comparability with other samples. The two continuous scales were used for the subsequent multilevel analyses.

ple in this study. The analyses are carried out with the HLM6.02 software (Raudenbush, Bryk, Cheong, & Congdon, 2004). Multilevel regression analyses are the appropriate method for analyzing nested data (weekly alliance ratings are nested within patients). To estimate the average alliance development in this inpatient sample, a three-level model was computed, reflecting the nested structure of the data (weekly measurements are nested within patients, patients are nested within therapists). The nested design of the data is depicted in Figure 1. Intraclass correlations derived from an intercept only model revealed that 56.3% of the variance are at the patient level (␳patient ⫽ .563) and 6.6% of variance are at the therapist level (␳therapist ⫽ .066). Therapist differences were significant (␹2 ⫽ 58.6; p ⬍ .01). The results of the regression analysis using three alliance development parameters are depicted in Table 1. The fixed effects show a linear increase in alliance ratings over time (positive slope parameter), but no indication for a U-shaped or an inverted U-shaped profile (nonsignificant curve parameter). However, as the regression analysis reflects the average alliance course over time, there is room for variations in both slope and curve parameters for patient and therapist subgroups. The random effects displayed in Table 1 show significant differences for most of the parameters, indicating that patients and therapists differ in the alliance level (intercept), increase, and curvature.

Results Description of Alliance Development The method used to describe alliance development is similar to the procedure used by Stiles et al. (2004). They modeled alliance development in a regression equation including a linear and a quadratic parameter, predicting alliance scores from the centered session number. The regression equation states: Alliance ⫽ Intercept ⫹ Slope (CW) ⫹ Curve (CW2) ⫹ Residual As session or week numbers were centered (CW), the (midtreatment) intercept was placed in the middle of the treatment. In addition, the centered profile ensured that the quadratic parameter (CW2) described degrees of symmetrically positively accelerated (U-shaped) or negatively accelerated (inverted U-shaped) curvature. However, unlike Stiles et al., who computed the parameters separately for each patient and used them for further analyses, the parameters are estimated in a multilevel regression analysis for the entire sam-

Level 3: therapists

Patients’ Interpersonal Problems In a second step, patients’ interpersonal problems were examined as potential explanatory variable for patient differences. Patients reported high levels of interpersonal distress before ther-

therapist 2

therapist 1

Level 2: patients

1

Level 1: weeks 1 2

3

2

… 1 2

3

3

… 1 2

3

…

….

1

1 2

3

2

… 1 2

3

3

… 1 2

3

…

N = 12 therapists

…

N = 281 patients

….

N = 3,208 measurements

FIGURE 1. The nested structure of the data. The illustrative path diagram on the left side is supplemented by the number of measurements on each level in this study on the right side.

282

Special Section: Therapists’ Attachment TABLE 1. Alliance Development Parameters in a Three-Level Regression Analysis of Weekly IES Alliance Scores Fixed effect Midtreatment intercept Slope (centered week) Curve (centered week2) Random effect Level 1 Error variance Level 2 Midtreatment intercept Slope (centered week) Curve (centered week2) Level 3 Midtreatment intercept Slope (centered week) Curve (centered week2)

Coefficient

SE

⬃t-ratio

df

p value

4.687 0.018 ⫺0.001

0.0923 0.0085 0.0013

50.75 2.18 ⫺1.08

11 11 11

⬍.01 .05 .31

Variance component

SD

␹2

df

p value

0.478

0.6917

0.457 0.004 0.0002

0.6760 0.0672 0.0135

1594.6 637.6 517.3

269 269 269

⬍.01 ⬍.01 ⬍.01

0.074 0.001 0.00001

0.2722 0.0214 0.0028

53.6 25.0 9.8

11 11 11

⬍.01 ⬍.01 ⬎.50

Note. IES ⫽ Inpatient Experience Scale.

apy (IIP total score M ⫽ 1.61; SD ⫽ 0.59). Most patients described themselves as submissive and slightly affiliative (IIP control M ⫽ ⫺0.54, SD ⫽ 0.49; IIP affiliation M ⫽ 0.21, SD ⫽ 0.46). We conducted separate analyses of all three IIP variables (total score, affiliation, control) for all three alliance development parameters (intercept, slope, curve). When examined separately, the IIP total score emerged as negative predictor for the intercept (coefficient ⫺.16, t ⫽ ⫺1.81, p ⬍ .10), whereas the IIP affiliation score was positively related to the intercept (coefficient .20; t ⫽ 2.03; p ⬍ .07), indicating that more severely distressed patients had lower quality alliances, whereas the therapeutic relationships tended to be better for patients with interpersonal problems related to affiliation. The IIP control score was associated with a negatively accelerated (inverted U-shaped) curve (coefficient ⫺0.006; tdf ⫽11 ⫽ ⫺1.86; p ⬍ .10), suggesting that more dominant patients tended to have inverted U-shaped alliance curves. No significant predictors were found for the slope parameters. We then computed a multilevel model with all patient predictors on the second level that had been significant (up to an error probability of p ⫽ .10) as single predictors when examined separately. In addition, patient dominance was included as predictor of the intercept (see Table 2). When accounting for patients’ IIP control, the curve parameter approached significance, indicating that on average, patients tended to have an inverted U-shaped alliance curve. The inclusion of patient IIP scores in the model resulted in an increase of explained variance com-

pared to the first model: patient residual intercept variance was reduced by 9.0% of and therapist residual intercept variance was reduced by 14.9%. Therapists’ Attachment and Interaction Effects As next step, therapists’ attachment representations were investigated as possible predictors of alliance development. For descriptive reasons, frequencies of attachment categories in the therapist sample are reported. About half of the 12 therapists fell into the category of secure attachment (n ⫽ 7; 58.3%). The remaining therapists were mostly classified as preoccupied (n ⫽ 4; 33.3%). One therapist (8.3%) showed signs of unresolved attachment. The secondary organized strategy assigned to this therapist was dismissive. The trend toward a higher degree of attachment preoccupation in the therapist sample was also reflected in the continuous AAI scales: The mean of the “dismissive-versus-preoccupied” dimension was M ⫽ ⫺2.40 (SD ⫽ 1.32). The “secure-versus-insecure” mean was M ⫽ 0.40 (SD ⫽ 1.19), reflecting the almost equal distribution of secure and insecure attachment categories. The two continuous scores were used for further analyses. To relate therapists’ attachment to alliance development, therapists’ AAI dimensions “secureversus-insecure” as well as “dismissive-versuspreoccupied” were entered as predictors for each of the alliance development parameters (intercept, slope, curve) on the third level. Similar to

283

Dinger, Strack, Sachsse, and Schauenburg TABLE 2. Patients’ Interpersonal Problems and Alliance Development Parameters in a Three-Level Regression Analysis of Weekly IES Alliance Scores Fixed effects

Coefficient

SE

⬃t-ratio

df

p value

Midtreatment intercept Intercept ⫻ IIP total (patient) Intercept ⫻ IIP affiliation (patient) Intercept ⫻ IIP control (patient) Slope (centered session) Curve (centered session2) Curve ⫻ IIP control (patient)

4.912 ⫺0.191 0.180 ⫺0.070 0.016 ⫺0.004 ⫺0.006

0.1324 0.0641 0.0974 0.0777 0.0089 0.0021 0.0032

37.10 ⫺2.98 1.85 ⫺0.91 1.82 ⫺2.114 ⫺1.83

11 11 11 11 11 11 11

⬍.01 .01 .09 .39 .10 .06 .09

Random effects

Variance component

SD

␹2

df

p value

Level 1 Error variance Level 2 Midtreatment intercept Slope (centered week) Curve (centered week2) Level 3 Midtreatment intercept Intercept ⫻ IIP total Intercept ⫻ IIP affiliation Intercept ⫻ IIP control Slope (centered week) Curve (centered week2) Curve ⫻ IIP control

0.479

0.6921

0.416 0.004 0.0002

0.6448 0.0664 0.0127

1386.3 636.7 476.3

233 269 257

⬍.01 ⬍.01 ⬍.01

0.063 0.012 0.061 0.028 0.0006 0.00002 0.00005

0.2511 0.1091 0.2473 0.1662 0.0251 0.0043 0.0068

15.1 8.5 12.9 9.6 26.4 14.8 19.4

11 11 11 11 11 11 11

.18 ⬎.50 .30 ⬎.50 ⬍.01 .19 .05


the procedure described for patients, both attachment scores were examined separately for each of the three alliance development parameters. The degree of therapist preoccupation was significantly associated with the intercept (coefficient .09, t ⫽ 3.51, p ⬍ .01) and negatively related to the curve parameter, indicating that more dismissing therapists had more positive alliances and tended to have inverted U-shaped curves. No other significant correlations were found and the AAI variable “secure-insecure” was not related to any of the alliance development parameters. In a last step, patients’ interpersonal problems and therapists’ attachment were examined together to test possible interaction effects between patient and therapist variables. For each patient variable (IIP total, affiliation, and control), an interaction term with both therapist variables (secure-insecure, dismissive-preoccupied) was examined for each of the three development parameters (intercept, slope, curve), each time also including the respective variables as main effects. The only significant interaction that emerged was between IIP total (patient) and AAI preoccupation (therapist) for the quadratic curve parameter. When accounting for the interaction with patient

284

interpersonal distress, therapists’ attachment preoccupation also emerged as independent predictor of an inverted U-shaped curve. The final model included each variable that had been significant as a single predictor as well as the interaction between patients’ IIP total score and therapists’ AAI preoccupation for the curve parameter. In addition, patient dominance was included as predictor of the intercept (see Table 3). The interaction effect between therapist attachment preoccupation and patient IIP total score is also depicted in Figure 2. Highly preoccupied therapists are predicted to have alliances of lower qualities as well as an inverted U-shaped curve with interpersonally distressed patients. Therapists with lower attachment preoccupation, who tend more toward dismissiveness, have better alliances with patients who report fewer interpersonal problems. These alliances also show an inverted U-shaped pattern. Compared to the first model without any patient or therapist variables, the final model was able to explain more variance: patient intercept variance was reduced by 9.1% (indicating that the inclusion of therapist variables did not reduce patient intercept variance above the reduction by the second model), and

Special Section: Therapists’ Attachment TABLE 3. Final Model of Therapist Attachment, Patient Interpersonal Problems, and Alliance Development Parameters in a Three-Level Regression Analysis of Weekly IES Alliance Scores Fixed effects

Coefficient

SE

⬃t-ratio

df

p value

Midtreatment intercept Intercept ⫻ IIP total (patient) Intercept ⫻ IIP affiliation (patient) Intercept ⫻ IIP control (patient) Intercept ⫻ dismissive-preoccupied (therapist) Slope (centered session) Curve (centered session2) Curve ⫻ IIP total (patient) Curve ⫻ IIP control (patient) Curve ⫻ dismissive-preoccupied (therapist) Curve ⫻ dismissive-preoccupied (ther) ⫻ IIP total (pat)

5.192 ⫺0.189 0.177 ⫺0.079 0.118 0.016 ⫺0.016 0.007 ⫺0.006 ⫺0.005 0.003

0.148 0.064 0.095 0.079 0.026 0.009 0.008 0.005 0.003 0.002 0.001

35.02 ⫺2.95 1.87 ⫺0.99 4.52 1.76 ⫺1.84 1.37 ⫺1.77 ⫺2.16 2.25

10 11 11 11 10 11 10 10 11 10 10

⬍.01 .01 .09 .34 ⬍.01 .10 .10 .20 .10 .06 .05

Random effects

Variance component

SD

␹2

df

p value

Level 1 Error variance Level 2 Midtreatment intercept Slope (centered week) Curve (centered week2) Level 3 Midtreatment intercept Intercept ⫻ IIP total score Intercept ⫻ IIP affiliation Intercept ⫻ IIP control Slope (centered week) Curve (centered week2) Curve ⫻ IIP total score Curve ⫻ IIP control

0.480

0.693

0.415 0.004 0.001

0.644 0.066 0.012

1367.4 639.1 448.5

233 269 245

⬍.01 ⬍.01 ⬍.01

0.046 0.009 0.053 0.030 0.0006 0.00009 0.00003 0.00001

0.215 0.095 0.231 0.173 0.025 0.009 0.004 0.006

12.1 5.9 13.1 9.5 26.6 12.8 8.6 15.1

10 11 11 11 11 10 10 11

.28 ⬎.50 .28 ⬎.50 ⬍.01 .23 ⬎.50 .18


therapist intercept variance was reduced by 37.8%. Summarizing the results, alliance quality increased over time. Patients’ interpersonal problems were related mainly to the intercept, that is, the level of alliance quality. Specifically, the degree of interpersonal distress was associated with alliances of lower quality, whereas patients with problems related to affiliation had better alliances. Interpersonal problems related to control were associated with U-shaped alliance curves. In addition, therapist attachment preoccupation emerged as predictor of the intercept and interacted with patient level of interpersonal distress for the curve. Preoccupied therapists had inverted U-shaped alliance curves with highly distressed patients, but slightly U-shaped curves with less distressed patients. Most of the reported associations do not reach the conventional significant level of ␣ ⫽ .05, and are significant only under the more lenient ␣ ⫽ .10.

Discussion The focus of this study was the investigation of the influence of patients’ interpersonal problems, therapists’ attachment variables and their interaction on the development of the therapeutic alliance over time. Alliance quality and degree of interpersonal problems were assessed from the patients’ perspective by questionnaire. Therapist attachment representations were assed with the AAI. The hypotheses were tested in a regression model including a linear and a quadratic parameter in addition to the (midtreatment) intercept. The model had previously been used by Stiles et al. (2004) and Kramer et al. (2008). Alliance quality tended to increase during therapy. This finding corresponds to those of previous researchers on alliance development (e.g., Kivlighan & Shaughnessy, 1995; Sauer et al., 2003). However, the magnitude of this increase is

285

Dinger, Strack, Sachsse, and Schauenburg

4,9

group 4 group 3

4,8

group 2

predicted alliance

4,7

average alliance development

4,6

4,5

4,4 group 1 4,3

4,2

1

2

3

4

5

6

7

8

9

10

11

12

week FIGURE 2. Predicted alliance development depending on therapists’ attachment preoccupation and patients’ interpersonal problems with average IIP affiliation and control. Group 1: high therapist AAI preoccupation, high patient IIP total score; Group 2: high therapist AAI preoccupation, low patient IIP total score; Group 3: low therapist AAI preoccupation, high patient IIP total score; Group 4: low therapist AAI preoccupation, low patient IIP total score. High/low preoccupation and high/low IIP scores were computed as sample mean ⫾1 SD. Note that for both high and low scores on the AAI dimension dismissiveness-versuspreoccupation, the score lies within the range of attachment preoccupation.

rather small and the parameter only reached a trend level in this investigation. The distribution of interpersonal problems with a strong tendency toward submissiveness and a smaller tendency toward affiliation is typical for psychotherapy inpatients (Davies-Osterkamp, Strauß, & Schmitz, 1996). Hypotheses regarding the influence of patient interpersonal problems on alliance level (intercept) were confirmed, partly on a trend level. Patients who described themselves as having problems with being “too friendly” tended to describe more positive alliances with their individual therapists. Patients with a great number of interpersonal difficulties, however, described less positive alliances. These findings are in line with previous research demonstrating positive effects of interpersonal problems related to affiliation and negative influences of severe interpersonal difficul-

286

ties for the therapeutic relationship (e.g., Gibbons et al., 2003; Hersoug et al., 2002). As in several other studies, the IIP control dimension was not related to the level of alliance quality. There were relatively equal numbers of secure versus insecure therapists, but among the insecure therapists there were more preoccupied than dismissive therapists. This was also reflected on the continuum dismissiveness-versus-preoccupation. A relatively low degree of dismissiveness among psychotherapists seems plausible, as one would expect that personal interests of applicants as well as selection criteria of graduate psychodynamic psychotherapy institutes would result in more “relationship-oriented” therapists compared to the general population. Higher attachment preoccupation of therapists was associated with lower overall level of alli-

Special Section: Therapists’ Attachment ance quality and an inverted U-shaped curve with interpersonally distressed patients. Contrary to the findings from Sauer et al. (2003) and our expectations, most therapists in this study had an initial increase in alliance ratings of their patients, not only those with higher attachment anxiety. The expected decline of alliance quality over the course of therapy for preoccupied therapists was found only for highly preoccupied therapists treating interpersonally distressed patients. However, our finding that preoccupied therapists have a lower overall level of alliance quality corresponds to the reduced alliance quality of therapists with high attachment anxiety at Session 7 that had been reported by Sauer et al. (2003). One possible, though speculative, explanation could be that the hyperactivating attachment strategies displayed by preoccupied individuals in attachment relationships (clinging, effort to control others to minimize distance) also occur in the professional therapy relationship. This might lead patients to draw back from the therapist and experience the alliance as less positive. The findings from Rubino et al. (2000) are indicators for possible underlying mechanisms. They found a lower degree of empathy in therapists with higher attachment anxiety as assessed by questionnaire. Therapists with higher degrees of attachment preoccupation might be too involved with their own fear of abandonment and desire for closeness, resulting in a reduced capacity to respond with true empathy to their patients’ needs. This line of argumentation fits well with recent conceptualizations of countertransference management. There are some indications for an association between therapist attachment and countertransference behavior as rated by supervisors (Mohr, Gelso, & Hill, 2005); and countertransference behavior that is not understood and controlled is likely to injure the therapeutic process (Gelso & Hayes, 2001). Countertransference management as conceptualized by Gelso and colleagues requires five attributes of the therapist: self-insight, self-integration, anxiety management, conceptualizing skills, and empathy (Gelso, Latts, Gomez, & Fassinger, 2002). The problems for highly preoccupied therapists might be that they have strong emotional countertransference reactions and at the same time lower capacities of countertransference management, resulting in problematic countertransference behaviors. Because of their hyperactivating attachment strategy, one would expect mostly overin-

volved countertransference behaviors, for example, talking too much, agreeing too often with the patient, or taking an oversupportive stance with the patient (Friedman & Gelso, 2000). These problems should manifest itself, especially when treating more “difficult” patients, suffering from more severe interpersonal dysfunctioning. We did not find any influences of therapists’ attachment security-versus-insecurity dimension on the therapeutic relationship. In this study, insecurely attached therapists were as successful in establishing therapeutic alliances as their securely attached colleagues, contradicting the hypothesis that secure therapists can adapt better to their patients’ needs and construct better alliances (Halpern, 2003). It is possible that the professional skills of the therapists outweighed the influence of attachment security. The insecurely attached therapists in this sample may have more problematic representations of their personal attachment relationships, but seem nevertheless able to relate to their patients in a positive and meaningful way. The lower overall level of alliance quality that preoccupied therapists had in this sample was not found for retrospective alliance ratings, neither in the therapist sample of this study nor in a larger study on the influence of therapists’ attachment. This larger study investigated the influence of attachment representations of 31 therapists on outcome and retrospective alliance ratings and found that secure therapist attachment was only beneficial for symptom reduction, when therapists treated patients with greater disturbances (Schauenburg et al., in press). Therapists’ attachment preoccupation was neither related to symptomatic outcome nor to retrospective alliance ratings. The 12 therapists that were studied here were also included the outcome study. We assume that the reason for the diverging findings concerning the different alliance measures lies in the time point of assessment. Retrospective alliance ratings are likely to be influenced by outcome, and it seems reasonable that the weekly IES alliance measures are able to capture greater subtleties in patients’ perception of the alliance, simply because they are assessed throughout treatment. One aspect that deserves discussion pertains to additional patient factors that were not considered here. Patients’ interpersonal problems were included in this study, but there are many more

287

Dinger, Strack, Sachsse, and Schauenburg patient variables that can be expected to interact with therapists’ attachment representations, among which patients’ attachment characteristics are the most obvious. Attachment styles can easily be assessed by questionnaires and have been studied by many researchers before (e.g., Janzen, Fitzpatrick, & Drapeau, 2008; Tasca, Balfour, Ritchie, & Bissada, 2007). However, the additional assessment of patients’ partly unconscious attachment representations (although timeconsuming and costly, if done via interview) is necessary to understand better from an attachment point of view what both interaction partners contribute to the alliance and analyze possible matching effects. Although this has already been done for single-point outcome and alliance ratings, it also seems relevant for the investigation of alliance development over time. Most of the associations reported in this study are small and only reached the alpha level of .10. They should therefore be treated with caution. Especially the associations between therapists’ attachment representations and alliance development found in this sample are preliminary and cannot be generalized. Some limitations have to be taken into account. First of all, the therapist sample (N ⫽ 12) is very small and needs to be increased in future studies. As a rule of thumb, Hox (2002) recommends a sample size of at least 30 groups with at least 30 individuals per group to be on the safe side for researchers interested in fixed effects. However, he also acknowledges that statistical power has to be balanced against data collection reality. The lack of power because of the small therapist sample may be one reason for the nonsignificance of the reported associations. A second limitation concerns the bias in therapist theoretical orientation: we looked at a selected sample, as mostly psychodynamic oriented therapists were included. Future studies should concentrate on a more representative therapist sample or even compare therapists from different theoretical orientations. It is further unclear to what extent the alliance to an individual therapist in inpatient psychotherapy differs from the experience of a therapeutic alliance to a therapist in outpatient therapy. Another limitation concerns the role of patients’ improvement on the development of the therapeutic alliance. It is not clear, how alliance development is related to symptom improvement, but it is likely that the influence is bidirectional (positive alliances facilitate therapeutic work and therefore lead to im-

288

provement, but at the same time, symptomatic improvement enhances the relationship quality between patient and therapist). Some additional methodological points also limit the generalizability of the findings. The AAI classifications stem from only one certified AAI coder. Although the procedures for AAI coding require extensive training and a reliability check before the certification for each coder, we have no data from a second certified coder for a comparison. Therefore, the possibility of a rating bias cannot be ruled out. A further limitation lies in the alliance measure. The alliance scale of the IES was developed based on items of the German version of the Helping Alliance Questionnaire (Bassler et al., 1995). However, no validation study correlating the IES scale with other established measures of alliance quality has been reported. In addition, the internal consistency of the four-item scale is not high (Cronbach’s alpha ⫽ .71), which complicates interpretation of the findings. The scale was chosen, because it is well suited for weekly routine assessments in an inpatient setting. However, the economic advantage of very short scales is traded for lower reliability of measurement. Finally, the final regression model still shows random effects, especially on the patient level, meaning that there is still significant variation that was not explained by the variables included in this study. These issues demand for caution in generalizing the results from this study to other therapist populations in different settings. We believe, however, that this study will be of interest to psychotherapy researchers despite of its limitations. In addition to the reliable standard instrument for the assessment of interpersonal problems, we used extensive interviews and a standardized coding procedure to assess therapists’ attachment representations. We also included a sufficient number of patients per therapists. These methodological strengths do not compensate for the low therapist sample size, but increase reliability of the findings. This is one of the first published studies investigating influences of therapist variables and their interaction with patient factors on alliance development. This research demonstrates the possibility of reducing a complex development course over time to a few parameters that can be related to patient and therapist variables in a second step. We hope that future research will continue to look at similar

Special Section: Therapists’ Attachment process variables and investigate alliance development over time. References ACKERMAN, S. J., & HILSENROTH, M. J. (2003). A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review, 23, 1–33. ALDEN, L. E., WIGGINS, J. S., & PINCUS, A. L. (1990). Construction of circumplex scales for the Inventory of Interpersonal Problems. Journal of Personality Assessment, 55, 521–536. BAKERMANS-KRANENBURG, M., & VAN IJZENDOORN, M. H. (1993). A psychometric study of the Adult Attachment Interview: Reliability and discriminant validity. Developmental Psychology, 29, 870 – 879. BASSLER, M., POTRATZ, B., & KRAUTHAUSER, H. (1995). Der “Helping Alliance Questionnaire” HAQ von Luborsky [The “Helping Alliance Questionnaire” (HAQ) by Luborsky]. Psychotherapeut, 40, 23–32. BERETTA, V., DE ROTEN, Y., STIGLER, M., DRAPEAU, M., FISCHER, M., & DESPLAND, J.-N. (2005). The influence of patient’s interpersonal schemas on early alliance building. Swiss Journal of Psychology, 64, 13–20. BORDIN, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, Practice, Training, 16, 252–260. BOWLBY, J. (1988). A secure base. Clinical applications of attachment theory. London: Routledge. BRAEHLER, E., HOROWITZ, L., KORDY, H., SCHUHMACHER, J., & STRAUSS, B. (1999). Zur Validierung des Inventars Interpersoneller Probleme (IIP)–Ergebnisse einer Repra¨sentativbefragung in Ost- und Westdeutschland [Validation of the Inventory of Interpersonal Problems (IIP)–results of a representative study in East and West Germany]. Psychotherapie, Psychosomatik, Medizinische Psychologie, 49, 422– 431. CONSTANTINO, M. J., ARNOW, B. A., BLASEY, C., & AGRAS, W. J. (2005). The association between patient characteristics and the therapeutic alliance in cognitivebehavioral and interpersonal therapy for Bulimia Nervosa. Journal of Consulting and Clinical Psychology, 73, 203–211. DANIEL, S. I. F. (2006). Adult attachment patterns and individual psychotherapy: A review. Clinical Psychology Review, 26, 968 –984. DAVIES-OSTERKAMP, S., STRAU〉, B., & SCHMITZ, N. (1996). Interpersonal problems as predictors of symptom-related treatment outcome in longtermpsychotherapy. Psychotherapy Research, 6, 164 –176. DE ROTEN, Y., FISCHER, M., DRAPEAU, M., BERETTA, V., KRAMER, U., FAVRE, N., ET AL. (2004). Is one assessment enough? Patterns of helping alliance development and outcome. Clinical Psychology and Psychotherapy, 11, 324 –331. DINGER, U., & SCHAUENBURG, H. (2008). Alliance development and therapeutic outcome in Inpatient Psychotherapy. Paper presented at the international meeting of the Society for Psychotherapy Research, Barcelona, Spain. DINGER, U., STRACK, M., LEICHSENRING, F., & SCHAUENBURG, H. (2007). Influences of patients and therapists

interpersonal problems and therapeutic alliance on outcome in psychotherapy. Psychotherapy Research, 17, 149 –161. DINGER, U., STRACK, M., LEICHSENRING, F., WILMERS, F., & SCHAUENBURG, H. (2008). Therapist effects on outcome and alliance in inpatient psychotherapy. Journal of Clinical Psychology, 64, 344 –354. FONAGY, P., STEELE, H., & STEELE, M. (1991). Maternal representations of attachment during pregnancy predict the organization of infant-mother attachment at one year of age. Child Development, 62, 891–905. FRALEY, R. C., & SPIEKER, S. J. (2003). Are infant attachment patterns continuously or categorically distributed? A taxometric analysis of strange situation behavior. Developmental Psychology, 39, 387– 404. FRANKE, G. (1995). SCL-90-R. Die Symptom-Checkliste von Derogatis. [SCL-90-R. Symptom Checklist by Derogatis]. Weinheim: Beltz. FRIEDMAN, S. M., & GELSO, C. J. (2000). The development of the Inventory of Countertransference Behavior. Journal of Clinical Psychology, 56, 1221–1235. GELSO, C. J., & CARTER, C. A. (1994). Components of the psychotherapy relationship: Their interaction and unfolding during treatment. Journal of Counseling Psychology, 41, 296 –306. GELSO, C. J., & HAYES, J. A. (2001). Countertransference management. Psychotherapy: Theory, Research, Practice, Training, 38, 418 – 422. GELSO, C. J., LATTS, M. G., GOMEZ, M. J., & FASSINGER, R. E. (2002). Countertransference management and therapy outcome: An initial evaluation. Journal of Clinical Psychology, 58, 861– 867. GEORGE, C., KAPLAN, N., & MAIN, M. (1996). Adult Attachment Interview. Unpublished manuscript, University of California. GIBBONS, M. B. C., CRITS-CHRISTOPH, P., DE LA CRUZ, C., BARBER, J. P., SIQUELAND, L., & GLADIS, M. (2003). Pretreatment expectations, interpersonal functioning, and symptoms in the prediction of the therapeutic alliance across supportive-expressive psychotherapy and cognitive therapy. Psychotherapy Research, 13, 59 –76. GROSSMANN, K. E., GROSSMANN, K., & WATERS, E. (2005). Attachment from infancy to adulthood. The major longitudinal studies. New York: Guilford Press. HALPERN, J. (2003). The capacity to be an analyst: A contribution from attachment research to the study of candidate selection. International Journal of Psychoanalysis, 84, 1605–1622. HERSOUG, A. G., HOGLEND, P., MONSEN, J. T., & HAVIK, O. E. (2002). Quality of working alliance in psychotherapy. Journal of Psychotherapy Practice and Research, 10, 205–216. HOROWITZ, L. M., STRAU〉, B., & KORDY, H. (2000). Das Inventar zur Erfassung interpersoneller Probleme IIP (2. Auflage) [The Inventory of Interpersonal Problems]. Weinheim: Beltz. HORVATH, A. O., & BEDI, P. B. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 37– 69). Oxford: University Press. HOX, J. (2002). Multilevel analyses: Techniques and applications. Mahwah, NJ: Erlbaum. IACOVIELLO, B. M., MCCARTHY, K. S., BARRETT, M. S., RYNN, M., GALOPP, R., & BARBER, J. (2007). Treatment preferences affect therapeutic alliance: Implica-

289

Dinger, Strack, Sachsse, and Schauenburg tion for Randomized Controlled Trials. Journal of Counseling and Clinical Psychology, 75, 194 –198. JANZEN, J., FITZPATRICK, M., & DRAPEAU, M. (2008). Processes involved in client-nominated relationship building incidents: Client attachment, attachment to therapist, and session impact. Psychotherapy: Theory, Research, Practice, Training, 45, 377–390. JOHANSSON, H., & EKLUND, M. (2006). Helping alliance and early dropout from psychiatric outpatient care. The influence of patient factors. Social Psychiatry and Psychiatric Epidemiology, 41, 140 –147. KIESLER, D. J. (1983). The 1982 Interpersonal Circle: A taxonomy for complementarity in human transactions. Psychological Review, 90, 185–214. KIESLER, D. J., & WATKINS, L. (1989). Interpersonal complementarity and the therapeutic alliance: A study of relationship in psychotherapy. Psychotherapy, 26, 183–194. KIVLIGHAN, D., & SHAUGHNESSY, P. (1995). Analysis of the development of the Working Alliance using hierarchical linear modeling. Journal of Counseling Psychology, 42, 338 –349. KIVLIGHAN, D., & SHAUGHNESSY, P. (2000). Patterns of working alliance development: A typology of clients’ working alliance ratings. Journal of Counseling Psychology, 47, 362–371. KRAMER, U., DE ROTEN, Y., BERETTA, V., MICHEL, L., & DESPLAND, J.-L. (2008). Patients’ and therapists’ view of early alliance building in dynamic psychotherapy: Patterns and relation to outcome. Journal of Counseling Psychology, 55, 89 –95. LEARY, T. (1957). The interpersonal diagnosis of personality. New York: Ronald. LUBORSKY, L. (1984). Principles of psychodynamic psychotherapy. New York: Basic Books. MAIN, M., GOLDWYN, R., & HESSE, E. (2002). Adult attachment classification rating system. Unpublished Manuscript, University of California. MARTIN, D. J., GARSKE, J. P., & DAVIS, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438 – 450. MIKULINCER, M., SHAVER, P., & PEREG, D. (2003). Attachment theory and affect regulation: The dynamics, development, and cognitive consequences of attachment-related strategies. Motivation and Emotion, 27, 77–102. MOHR, J. J., GELSO, C. J., & HILL, C. E. (2005). Client and counselor trainee attachment as predictors of session evaluation and countertransference behaviors in first counseling sessions. Journal of Counseling Psychology, 52, 298 –309. MURAN, J. C., SEGAL, Z. V., SAMSTAG, L. W., & CRAWFORD, C. E. (1994). Patient pretreatment interpersonal problems and therapeutic alliance in short-term cognitive therapy. Journal of Consulting and Clinical Psychology, 62, 185–190. PAIVIO, S. C., & BAHR, L. M. (1998). Interpersonal prob-

290

lems, working alliance and outcome in short-term experiential therapy. Psychotherapy Research, 8, 392– 407. PUSCHNER, B., KRAFT, S., & BAUER, S. (2005). Interpersonal problems and outcome in outpatient psychotherapy: Findings from a long-term longitudinal study in Germany. Journal of Personality Assessment, 83, 223– 234. RAUDENBUSH, S., BRYK, A., CHEONG, Y. F., & CONGDON, R. (2004). HLM 6. Hierarchical Linear and Nonlinear Modeling. Chicago: Scientific Software International. RUBINO, G., BARKER, C., ROTH, T., & FEARON, P. (2000). Therapist empathy and depth of interpretation in response to potential alliance ruptures: The role of therapist and patient attachment styles. Psychotherapy Research, 10, 408 – 420. SAMMET, I., & SCHAUENBURG, H. (1999). Stationserfahrungsbogen – SEB. Manual und Auswertungsbogen. [Inpatient Experience Scale IES. Manual and Scoring Sheet]. Weinheim, Beltz. SAUER, E. M., LOPEZ, F. G., & GORMLEY, B. (2003). Respective contribution of therapist and client adult attachment orientation to the development of the early working alliance: A preliminary growth modeling study. Psychotherapy Research, 13, 371–382. SAUNDERS, S. M. (2001). Pretreatment correlates of the therapeutic bond. Journal of Clinical Psychology, 57, 1339 –1352. SCHAUENBURG, H., BUCHHEIM, A., BECKH, K., NOLTE, T., BRENK, K., LEICHSENRING, F., ET AL. (in press). The influence of psychodynamically-oriented therapist’s attachment representations on outcome and alliance in inpatient psychotherapy. Psychotherapy Research. SCHAUENBURG, H., SAMMET, I., & STRACK, M. (2001). Verlauf der Symptombelastung und Vorhersage des Behandlungserfolges in der stationa¨ren Psychotherapy [Course of symptom severity and prediction of outcome in inpatient psychotherapy]. Zeitschrift fu¨r Psychosomatische Medizin und Psychotherapie, 47, 380 –395. STILES, W. B., GLICK, M. J., OSATUKE, K., HARDY, G. E., SHAPIRO, D. A., AGNEW-DAVIES, R., ET AL. (2004). Patterns of alliance development and the rupturerepair hypothesis: Are productive relationships U-shaped or V-shaped? Journal of Counseling Psychology, 51, 81–92. TASCA, G., BALFOUR, L., RITCHIE, K., & BISSADA, H. (2007). Change in attachment anxiety is associated with improved depression among women with binge eating disorder. Psychotherapy: Theory, Research, Practice, Training, 44, 423– 433. WATERS, E., CROWELL, J., ELLIOTT, M., CORCORAN, D., & TREBOUX, D. (2002). Bowlby’s Secure Base Theory and the Social/Personality Psychology of attachment styles: Work(s) in progress. Attachment and Human Development, 4, 230 –242. WATERS, E., TREBOUX, D., FYFFE, C., CROWELL, J., & CORCORAN, D. (2005). Scoring secure versus insecure and dismissing versus preoccupied attachment as continuous variables: Discriminant analysis using AAI state of mind scales. (unpublished manuscript).