Influences of Therapist-Client Attachment Styles on the Clinical Relationship

All therapists come into the clinical relationship with their own history of interpersonal relationships, learned tendencies, conceptions of self, and cultural influences. In the past, it was assumed that therapists were blank slates for the the client’s transference, but contemporary practitioners are acknowledging the role of intersubjectivity, adding the influence of the therapist’s subjectivity and the co-creation of the dynamics between therapist and client into consideration (Kahn, 1997). Attachment styles are developed through early relationships with primary caregivers and influence internal models of future relationships, including the therapeutic relationship. Therapists should be aware of their own attachment tendencies and how their behaviors might impact others so that they can be more intentional about responding to clients in a way that is healing and moves the therapeutic work forward. In this paper, I will provide an overview of attachment in adults and then discuss the impact of therapist-client attachment tendencies on building a therapeutic alliance, transference-countertransference dynamics, repairing ruptures in the relationship, and therapy outcomes.

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Overview of Adult Attachment

According to Bowlby (1969), a child’s primary attachment figures provide protection in times of need and a secure base from which they can explore the world (as cited by Mohr, Gelso, & Hill, 2005). A child’s attachment system is most strongly activated when they have a need (are ill, frightened, hungry, or stressed), and the child responds and behaves in ways that increase their chances of getting their needs met through the attention of their primary attachment figures (Bowlby, 1988 as cited by Mohr et al., 2005). A person’s attachment style develops in a way that reflects the degree to which their caregivers were able to attune to their needs and is persistent throughout their lifespan (Ainsworth, Blehar, Waters, & Wall, 1978; Ainsworth, 1989 as cited by Mohr et al., 2005). Children develop internal working models, in their sense of self and others, that guide their expectations, interpretations, feelings, and behaviors in relationships throughout their lives (Bretherton, 1985 as cited by Bernier & Dozier, 2002).

The two dimensions of attachment style are anxiety and avoidance. Anxiety is the level of sensitivity to cues of potential abandonment and rejection by attachment figures (Fraley & Shaver, 2000 as cited by Mohr et al., 2005). People with high anxiety might feel unworthy of love, be self-critical, fear abandonment, be chronically activated, feel pressure to manage their image, and not be able to tolerate conflict and negative feedback (Kobak & Sceery, 1988 as cited by Mohr et al., 2005; Mikulincer & Shaver, 2007 as cited by Marmarosh et al., 2015). Avoidance is the level in which individuals are comfortable relying on attachment figures in times of need (Fraley & Shaver, 2000 as cited by Mohr et al., 2005). People with high avoidance tend to avoid dependency, fear intimacy, minimize issues, avoid conflict, and be self-sufficient (Bowlby, 1988; Holmes, 2001; Wallin, 2005 as cited by Marmarosh et al., 2014).

There are 4 attachment styles, three of which are insecure and one of which is secure. People who have preoccupied attachment have high anxiety and low avoidance; they tend to have an intrusive and domineering style, exaggerate their personal distress, and have a high need for support and closeness. People who have fearful attachment have high anxiety and high avoidance; they tend to be socially avoidant and unassertive. People who have dismissing attachment have low anxiety and high avoidance; they tend to be cold, distant, self-reliant, mistrustful, and focus on personal strength over interpersonal relationships. People who have secure attachment have low anxiety and low avoidance; they tend to enjoy stable relationships without losing personal autonomy, practice empathetic listening, cooperate well, and are well-balanced because they had early caregivers who were responsive and warm (Bartholomew & Horowitz, 1991 as cited by Mohr et al., 2005; Dozier & Lee, 1995; Main & Goldwyn, 1998 as cited by Bernier & Dozier, 2002; Mikulincer & Nachson, 1991; Pistole, 1989 as cited by Ligiéro & Gelso, 2002). Insecure attachment styles are preoccupied, fearful, and dismissing. People with these attachment styles often have difficulty regulating their emotions and maintaining intimate relationships, often feeling a negative sense of themselves and others (Fonagy et al., 1996; Mikulincer & Shaver, 2005, 2007 as cited by Marmarosh et al., 2014).

Attachment and the Clinical Relationship

The clinical relationship stirs up anxieties and behavior patterns associated with the client’s attachment style because therapy involves vulnerability, caretaking, and intimacy (Bowlby, 1988 as cited by Mohr et al., 2005). More often than not, clients who come to therapy will have an insecure attachment style because they are often looking to improve their interpersonal relationships and/or suffer from symptoms that stem from issues in early relationships. In life, others will often respond in ways that perpetuate their internal model of relationships. For instance, a person with a preoccupied attachment style may act in a way that is dependent and fragile, and others will respond by taking care of them (Dozier et al., 1994). A therapist’s role is to be a secure base for the client while also negating the client’s working model of relationships by being appropriately available and responsive. This is difficult and must be done intentionally because we all tend to naturally respond in ways that confirm existing internal models of relationships in both ourselves and others (Bowlby, 1988; Snyder, 1981 as cited by Dozier et al., 1994).

The Working Alliance

The working alliance between therapist and client is influenced by an agreement on goals, the tasks needed to attain those goals, and the emotional bond between the two (Bordin, 1979 as cited by Ligiéro & Gelso, 2002). The quality of the therapeutic alliance has been shown to be an important predictor of outcomes (Horvath & Greenberg, 1989, 1994; Martin, Garske, & Davis, 2000 as cited by Ligiéro & Gelso, 2002). If a client feels insecure with their therapist, therapeutic exploration is impossible. The task of therapy is to create a secure space for the client to explore insecurity so that they can get to know themselves in relationship to others and start to distinguish between transferential vs. intentional responses (Holmes, 2010).

Clients tend to perceive the working alliance in ways that are similar to their general attachment style (Diene & Monroe, 2011). When clients have high attachment avoidance, many studies showed that they tend to have low ratings of the therapeutic alliance (Eames & Roth, 2000; Kivlighan, Patton, & Foote, 1998; Mallinckrodt, Coble, & Gantt, 1995; Satterfield & Lyddon, 1995 as cited by Mohr et al., 2005). This makes sense because deactivation and avoidance is inversely related to many of the activities in therapy such as help seeking, self-disclosure, and emotional vulnerability (Dozier, 1990 as cited by Mohr et al., 2005). When working with clients with avoidant tendencies, an important initial task is to prevent their attachment systems from becoming activated so that they can tolerate coming back to therapy. Strategies for building an alliance with avoidantly attached clients are to not go too far too soon in asking for emotional and personal vulnerability and disclosure, respecting and validating the client’s strengths and self-sufficiency, and communicating that you want to be there for the client but that it’s their choice to come back to the next session.

The therapist’s attachment style also affects how the client’s attachment system is activated (Mohr et al., 2005). When dismissing clients work with dismissing therapists, there tends to be a repudiation of the importance of the relationship. When dismissing clients work with preoccupied therapists, the therapy might be overly intense because the therapist wants a more intimate relationship than the client is ready for (Connors, 1997 as cited by Mohr et al., 2005). In working with clients with high attachment anxiety, therapists with lower attachment anxiety had higher client alliance ratings than therapists with high attachment anxiety, showing that a therapist with lower attachment anxiety might be able to ground and co-regulate with a highly anxious client more effectively than a therapist with high attachment anxiety (Marmorosh et al., 2014). When therapists had high levels of attachment avoidance, they tended to have lower client ratings of the working alliance (Dunkle & Friedlander, 1996 as cited by Mohr et al., 2005). A study by Romano, Fitzpatrick, & Janzen (2008) showed that highly avoidant therapists paired with highly anxious clients had less session depth (as cited by Marmarosh et al., 2014). These avoidantly attached therapists might tend to withdraw from their more anxious clients and be unable to attune to the clients’ emotional bids for intimacy and vulnerability.

Agreement between therapist and client perceptions of working alliance is correlated to treatment success, likely because agreement is associated with the therapist’s ability to read and respond to the client’s experience in therapy accurately (Pepinsky & Karst, 1964; Atzil-Solonim et al., 2015 as cited by O’Connor, Kivlighan, Hill, Gelso, & 2018). Therapists who had secure attachment styles tend to rate their early alliances with clients more positively than therapists who had anxious attachment (Black et al., 2005 as cited by Marmorosh et al., 2014). Therapists who had high attachment anxiety, however, also had high initial client ratings of working alliance, but their client alliance ratings dropped over time. This indicates that these highly anxious therapists may be extra sensitive to attuning to clients early on and avoiding confrontation and conflict. This may be helpful for establishing initial rapport but might not serve the client well in the long run (Sauer et al., 2003 as cited by Marmorosh et al., 2014). Therapists with lower attachment anxiety tracked the changes in their clients’ ratings more closely, indicating that they were better able to read and respond to their clients as therapy progressed (Kivlighan & Marmarosh, 2016 as cited by O’Connor et al., 2018).

Transference and Countertransference

The concept of countertransference has evolved over the years to include any feelings, thoughts, and behaviors that the therapist has in response to the client. Objective countertransference is the therapist’s reactions evoked by a client’s behaviors that anyone else might also have. These thoughts and feelings are information that can be useful in informing the therapeutic process as long as they are not acted upon without conscious reflection (Kiesler, 2001 as cited by Ligiéro & Gelso, 2002). Subjective countertransference is the “counselor’s observable reactions to clients that result from the counselor’s own unresolved issues and personal conflicts” (Gelso & Hayes, 1998 as cited by Mohr et al., 2005, pp. 300). This type of response is harmful to the therapeutic process and most likely to occur when the client and therapist differ in their patterns of attachment insecurity. Therapists with dismissing attachment style are most likely to be critical and rejecting of preoccupied clients. Likewise, preoccupied therapists are most likely to be hostile towards dismissing clients (Mohr et al., 2005).

Not all harmful countertransference behavior presents as negative as indicated above. Positive countertransference behavior can seem friendly and supportive but actually serves the therapist’s defensive needs by avoiding clients’ issues and the work of therapy. Therapists might respond with the positive countertransference behaviors of being overly supportive, agreeing too much, disclosing too much, and colluding with the client’s worldviews that might not be serving them (Friedman & Gelso, 2000 as cited by Ligiéro & Gelso, 2002). Negative countertransference behaviors are negatively correlated to the working alliance as rated by therapists and supervisors. Positive countertransference behaviors, however, are not related to the therapist’s rating of working alliance but are negatively related to the emotional bond as rated by their supervisors. This indicates that therapists might not be aware of when they are engaging in positive countertransference behaviors that might actually be harmful to the client’s growth process (Ligiéro & Gelso, 2002).

Ruptures and Repair

A therapist’s attachment security impacts their ability to identify and repair ruptures. Since anxiously attached people are more “inclined to be hypervigilant to abandonment and ruminate on interpersonal rejection,” it’s not surprising that more anxiously attached therapists tend to report more ruptures than more avoidant therapists (Mikulincer & Shaver, 2007 as cited by Marmorosh et al., 2015, pp. 141; Eames & Roth, 2000 as cited by Marmorosh et al., 2015). A study by Marmorosh et al. (2015) found that while therapists with higher anxiety focus more of their efforts on ruptures, they do not necessarily feel successful at repairing ruptures. High levels of therapist attachment anxiety is negatively correlated to empathetic responses to ruptures (Rubino et al., 2000 as cited by Marmorosh et al., 2014). An anxiously attached therapist could be flooded with emotional needs that might prevent them from responding in a way that attunes to their client’s needs (Marmorosh et al., 2014). Even though more dismissing therapists report the least number of ruptures, they also have the lowest client ratings of working alliance, which in part has to do with the therapist’s ability to repair ruptures (Marmorosh et al., 2015; Dunkle & Friedlander, 1996 as cited by Mohr et al., 2005). This paradox indicates that dismissing therapists might not be aware of ruptures that are happening in session due to their tendencies to avoid conflict and distance themselves from emotional vulnerability.

Attachment Styles and Therapy Outcomes

Therapist attachment security is correlated to stronger therapeutic alliances, greater session depth, more empathetic engagement, and more adaptability to the client’s needs (Rubino, Barker, Roth, & Fearon, 2000; Romano, Fitzpatrick, & Jansen, 2008; Dunkle & Friedlander, 1996 as cited by Marmorosh et al., 2015; Mallinckrodt, 2010 as cited by Marmorosh et al., 2014). In a study by Dozier, Davis & Barnett (1994), secure case managers, who weren’t trained as psychotherapists, were able to respond therapeutically to the underlying needs of their clients who were dismissing and preoccupied. They were able to look beyond the surface to challenge their clients’ models of the world and create corrective emotional experiences. Insecure case managers, on the other hand, responded only to their clients’ more obvious presentation of needs. They tended to intervene more intensively with preoccupied clients and less with dismissing clients, which resulted in the perpetuation of the client’s internal model of relationships. This shows that secure case managers may be more willing to intervene in ways that are uncomfortable for themselves and more therapeutic for the client in the long run (Cashdon, 1988; Marshall & Marshall, 1988 as cited by Dozier et al., 1994).

Contrasting interpersonal tendencies between therapists and clients have shown to be optimal for the outcome of treatment, corrective emotional experiences, and experiential relearning of interpersonal dynamics (Bowlby, 1973, 1980, 1982, 1988; Kiesler, 1982, 1996; Sullivan, 1953 as cited by Bernier & Dozier, 2002). The therapist’s natural stance helps to keep them from adopting positions that reinforce the client’s worldview (Bernier & Dozier, 2002). Complementary responses reinforce someone’s worldview (for example, being extra sheltering of preoccupied clients), whereas non-complementary responses challenge someone’s worldview of relationships (for example, giving preoccupied clients tools to cope with anxiety on their own). The most successful therapy starts with complementary responses so that the therapist and client can build trust and security, introduces non-complementary responses in the middle so that clients can work through learning different ways of relating, and returns to mostly complementary responses at the end of therapy (Dietzel & Abeles, 1975; Tracey, 1987; Carson, 1969; Kiesler, 1996 as cited by Bernier & Dozier, 2002). High levels of non-complementary responses, however, are associated with unsuccessful therapy (Tasca & McMullen, 1993 as cited by Bernier & Dozier, 2002). The key is to make gentle switches that maximize gains in a safe environment (Bernier & Dozier, 2002).

In working with clients who have dismissing attachment styles, therapists should resist the pull to focus on superficial issues and gently encourage the client to explore emotional issues and the value of relationships. In working with clients who are preoccupied, therapists should try to encourage more autonomy and independence (Bernier, Larose, & Soucy, 2001 as cited by Bernier & Dozier, 2002). Therapists who valued autonomy were shown to be more effective with clients who tended to be dependent, whereas therapists who valued connection were more effective with clients who were more avoidant (Berzins, 1977 as cited by Bernier & Dozier, 2002). Many studies showed that clients who are more avoidant are best served with secure therapists who lean more onto the anxious side, and more anxious clients are best served with secure therapists who fall more on the avoidant side (Bernier & Dozier, 2002; Dozier et al., 1994; Tyrrell et al., 1999 as cited by Marmorosh et al., 2014).

Clinical Implications

The body of research on attachment and the clinical relationship is at times inconclusive and conflicting because they all measure slightly different variables in slightly different ways. Many of the studies also have small sample sizes that are not representative of the population of people who use therapy; most of them use undergraduate psychology students as clients and therapists in training as therapists. Moreover, other confounding variables that affect the working alliance such as cultural differences, the client’s presenting issues, the level of attachment anxiety or avoidance, and the other attributes of the therapist are not evaluated. We should consider outcomes data with a grain of salt, but they do point to certain processes in therapy that practicing therapists can pay attention to based on their own and their client’s attachment style.

Therapists should know their tendencies and do their own internal work to build a more secure attachment style. They should also use their countertransference as information to be aware of and refrain from acting in ways that either reinforce their client’s internal model of relationships or serve their own needs. After building an awareness of their client’s attachment style, therapists can better understand the client’s signals and feelings about the relationship and act in ways that are more responsive to the client’s underlying needs rather than reactive to what’s on the surface (O’Connor et. al, 2018). In assessing and responding to a client’s attachment style, it’s also important to be culturally responsive. More collective cultures value interconnectedness and harmony more than individualistic cultures. What might seem like a hypersensitivity to what others think due to anxious attachment style can actually be a realistic way of being in that client’s culture. Therapists should be curious about the client’s feelings, thoughts, and behaviors in therapy, discuss their meaning, and explore the relevance to interpersonal relationships and expectations outside of therapy. With clients who are not part of the dominant culture, sometimes the work is helping clients better navigate their relationships in the different cultural environments that they exist in, outside of, and in between.

Conclusions

Therapists and clients come to the clinical relationship with attachment histories that were developed long before they started working together. To serve their clients effectively, therapists need to do the inner work of becoming aware of their attachment tendencies and start to shift their own patterns of relating towards becoming more secure. It’s the therapist’s role to hold hope for change, both in themselves and their clients. Through self-awareness and self-compassion, therapists can become more aware of their own attachment styles and move towards better being able to respond rather than react to both their own and their clients’ needs.

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