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This entry is our analysis of a review or synthesis of research findings added to the Effectiveness Bank. The original review was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text The Summary conveys the findings and views expressed in the review. Below is a commentary from Drug and Alcohol Findings.

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Adapting psychotherapy to the individual patient: Attachment style.

Levy K.N., Ellison W.D., Scott L.N. et al.
Journal of Clinical Psychology: 2011, 67(2), p. 193–203.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Levy at klevy@psu.edu.

Meta-analytic review commissioned by a US task force concludes that psychotherapy patients who feel secure in and easily form close and trusting intimate relationships have better outcomes, while the reverse is the case for those anxious about close relationships.

Summary Attachment theory, developed by Bowlby to explain human bonding, has profound implications for conducting and adapting psychotherapy. We summarise the prevailing definitions and measures of attachment style. Someone's characteristic ways of relating in intimate care-giving and care-receiving relationships with 'attachment figures', often parents, children, and romantic partners. The concept involves confidence (or the lack of it) in the availability of the attachment figure for use as a secure base from which one can freely explore the world when not in distress, as well as a safe haven from which one can seek support, protection and comfort in times of distress. We review the results of three meta-analyses examining the associations between the outcomes of psychotherapy and attachment styles characterised by anxiety Attachment anxiety relates to beliefs about self-worth and whether or not one will be accepted or rejected by others (http://en.wikipedia.org/wiki/Attachment_measures). about one's close relationships, avoidance, Attachment avoidance relates to beliefs about taking risks in approaching or avoiding other people. Avoidant individuals may feel it is very important to be independent and self-sufficient and prefer not to depend on others or have others depend on them, or they may want emotionally close relationships, but find it difficult to trust others completely, or to depend on them (http://en.wikipedia.org/wiki/Attachment_measures). or security. Defined in one schema by low attachment avoidance and low anxiety. Secure individuals find it relatively easy to become emotionally close to others, are comfortable depending on others and having others depend on them, and don't worry about being alone or having others not accept them (http://en.wikipedia.org/wiki/Attachment_measures). They are relatively open to exploring their surroundings and relationships. Evidence suggests that they tend to be open, collaborative, compliant, committed, and proactive in treatment, trusting of therapists, and, most important, able to integrate their therapists' comments. Fourteen studies of 19 separate therapy cohorts were synthesised, a combined sample size of 1467. Attachment anxiety was associated with worse post-therapy outcomes (an effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and experimental groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of the variability in the outcome across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. of -0.46), while attachment security was related to better outcomes (an effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and experimental groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of the variability in the outcome across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. of 0.37). Both were medium-size relations and statistically significant. In contrast, attachment avoidance evinced a negligible overall relation to outcomes. Overall in these 14 studies, clients' attachment styles appeared to contribute almost as much variance to psychotherapy outcomes as does the alliance between client and therapist, a well-established predictor of therapeutic change.

The age and gender composition of the patients moderated the relation between attachment security and outcome: samples with a higher proportion of female clients and a higher mean age showed a smaller relation between attachment security and outcome.

One limitation of our meta-analyses was that we could not control for the relation between attachment and pre-treatment functioning. This raises the possibility that any association between attachment and post-treatment functioning may, to some degree, merely reflect the relation between attachment and pre-treatment functioning rather than any differential impact of therapy.

We discuss the practice implications of our findings and related research. Among these are that therapists should assess the patient's attachment style because this can influence the psychotherapy process, the responses both of patients and therapists, the quality of the therapeutic alliance, and the ultimate outcomes of treatment. Formal interviewing or use of reliable self-report measures can be useful as part of the assessment process. Knowledge of the patient's attachment style can help the therapist anticipate how they may respond to the therapist's interventions and guide the therapist in calibrating to the patient's interpersonal style. For example, if the patient is dismissing People with this type of attachment style feel comfortable without close emotional relationships and that it is very important to feel independent and self-sufficient; they prefer not to depend on others or have others depend on them (http://en.wikipedia.org/wiki/Attachment_measures). Dismissing patients are often resistant to treatment, have difficulty asking for help, and retreat from help when it is offered. in his or her attachment, then the therapist may need to be more engaged. In contrast, if the patient is preoccupied People with this type of attachment style want to be completely emotionally intimate with others, but often feel others are reluctant to get as close as they would like. They are uncomfortable being without close relationships, but worry that others don't value them as much as they value others (http://en.wikipedia.org/wiki/Attachment_measures). Preoccupied individuals are often eager to discuss their worries and relationship difficulties as well as their own role in these problems. However, they be difficult to treat. Despite tending to present themselves as needy, they are no more compliant with treatment plans than dismissing individuals and they tend to show less improvement. in his or her attachment, then the therapist should consider a stance designed to help the patient contain his or her emotional experiences.


Findings logo commentary This article was in a special issue of the Journal of Clinical Psychology devoted to adapting psychotherapy to the individual patient. For other Findings entries from this issue, see:
What works for whom: tailoring psychotherapy to the person
Adapting psychotherapy to the individual patient: Stages of change
Adapting psychotherapy to the individual patient: Preferences
Adapting psychotherapy to the individual patient: Culture
Adapting psychotherapy to the individual patient: Coping style
Adapting psychotherapy to the individual patient: Resistance/reactance level
Adapting psychotherapy to the individual patient: Expectations
Adapting psychotherapy to the individual patient: Religion and spirituality

Last revised 09 March 2011

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