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Attachment style in both health professionals & their clients, therapeutic alliance & mindfulness

I had lunch with a health professional friend the other day.  Later he emailed me saying "The last few times we have met you have mentioned the importance of attachment style in determining aspects of the interaction between patients and health care professionals."  He went on to raise a series of questions about health professional-patient relationships, about the way that the attachment style of both health professional and patient can affect outcomes, about how adult attachment is measured and the possibility of improving attachment patterns, and about links between attachment & mindfulness.  Gosh a lot of interesting questions being raised here.

Phil Shaver & Mario Mikulincer are key figures in our evolving knowledge of attachment in adults and Phil Shaver's Adult Attachment Lab website at the University of California is well worth visiting.  I thought I had been around for a while, but Shaver's huge list of publications goes back to 1967.  It's possible to request copies of his papers and of central importance for this blog post is his 2012 publication "An attachment perspective on therapeutic processes and outcomes" with its abstract reading "Over the past decade there has been an explosion of interest in clinical applications of attachment theory. In the present paper, we briefly describe John Bowlby's model of therapeutic change, the therapeutic relationship, and the therapist's role in emotional healing. We then review empirical evidence for three key propositions in Bowlby's model. First, a client's sense of security during therapy is crucial for facilitating therapeutic work. Second, a therapist's own sense of security contributes to positive therapeutic outcomes. Third, attachment insecurities can be effectively reduced in therapy, and movement toward greater attachment security is central to achieving favorable therapeutic outcomes. In sum, research evidence confirms the importance of establishing what Bowlby called a safe haven and a secure base within a therapeutic relationship."

Awareness of attachment issues informs therapy, it doesn't dictate it.  I have written several blog posts about this area over the years.  Clicking on the "attachment" tag will list them, including the 2009 post "Assessing attachment in adults" which gives links to the widely used 36-item "Experiences in close relationships - revised (ECR-R)" questionnaire.  Since I wrote that blog post, Chris Fraley & colleagues at Illinois University have published the important 2011 paper "The experiences in close relationships-relationship structures questionnaire: A method for assessing attachment orientations across relationships" with its abstract reading "Most research on adult attachment is based on the assumption that working models are relatively general and trait-like. Recent research, however, suggests that people develop attachment representations that are relationship-specific, leading people to hold distinct working models in different relationships. The authors report a measure, the Relationship Structures questionnaire of the Experiences in Close Relationships-Revised (ECR-RS; R. C. Fraley, N. G. Waller, & K. A. Brennan, 2000), that is designed to assess attachment dimensions in multiple contexts. Based on a sample of over 21,000 individuals studied online, it is shown that ECR-RS scores are reliable and have a structure similar to those produced by other measures. In Study 2 (N = 388), it is shown that relationship-specific measures of attachment generally predict intra- and interpersonal outcomes better than broader attachment measures but that broader measures predict personality traits better than relationship-specific measures."

So it seems likely that patients may well have attachment styles with health professionals that differ somewhat from, for example, their attachment style with their own parents or their spouse (but they may well be linked).  Similarly a health professional's provision of care for their patients may well differ from their provision of care for their children, spouse or friends (but again they may well be linked).  And it's worth pointing out here that care-seeking (attachment) and care-giving systems are likely to be related, but they are different - see the post "Behavioural systems: attachment (care seeking), care giving, exploration, sex, & power" and Mikulincer & Shaver's 2011 book chapter "Adult attachment and caregiving: Individual differences in providing a safe haven and secure base to others" for more on this.  Fraley has a great website that looks a bit more "current" than Shaver's.  Superbly it gives full text PDF's of most of his publications.  It also gives an extremely useful set of "links & resources" including details & expert advice on using both the ECR-R and the ECR-RS questionnaires.  The latter, by the way, only involves 9 items in contrast to the 36 items of the ECR-R.  In tomorrow's blog post I write more about the ECR-RS and provide downloadable copies of this interesting & useful questionnaire.

Very interesting stuff.  As Oscar Wilde put it "The truth is rarely pure and never simple".  So there are a whole bunch of research studies assessing the attachment styles of various groups of health professionals.  They're interesting, but I ask myself whether it would have been more helpful to assess care-giving patterns rather than care-seeking in these groups.  Heigh-ho, the issue of attachment styles in health professionals and other care-providing groups is still a worthwhile question in a whole series of ways.  For example Black & colleagues, back in 2005, published the paper "Self-reported attachment styles and therapeutic orientation of therapists and their relationship with reported general alliance quality and problems in therapy" with its abstract stating "The aims of this study were to explore the relationship between therapists' self-reported attachment styles and therapeutic orientation with the self-reported general therapeutic alliance and therapist-reported problems in psychological therapy.  A sample of 491 psychotherapists from differing therapeutic orientations responded to a postal questionnaire. The questionnaire contained standardized measures of therapeutic alliance quality, attachment behaviours, a checklist of problems in therapy, and a brief personality inventory.  Therapist-reported attachment styles generally explained a significant additional proportion of the variance in alliance and problems in therapy, over and above variance explained by general personality variables.  Self-reported secure attachment style was significantly positively correlated with therapist-reported general good alliance.  Self-reported anxious attachment styles were significantly negatively correlated with good alliance, and significantly positively correlated with the number of therapist-reported problems in therapy.  Therapeutic orientation independently predicted a small but significant amount of the variance in reported general alliance quality in addition to that explained by attachment behaviours."

Our attachment style affects how helpful & effective we are in many different situations.  Unsurprisingly this is true for parents - "Adult attachment style and parental responsiveness during a stressful event" - but it is also true in the military - "Leaders as attachment figures: Leaders' attachment orientations predict leadership-related mental representations and followers' performance and mental health"  - and in more general work environments too - "Attachment at work and performance".  Attachment subtly & powerfully affects therapeutic outcomes, probably as much through body language, facial expression & voice tone as through verbal content.  Many benefits may be transmitted through improvements in emotion regulation and this mechanism is likely to be important in mindfulness training's beneficial effects on insecure forms of attachment.  Happily attachment patterns can change & therapy can help this happen.  For over three dozen research abstracts/links covering these and other attachment-relevant topics click here.

One of the most interesting writers on this topic is Dr David Wallin.  His book "Attachment in psychotherapy" gained rave reviews.  You know something is hitting the bull's eye when Phil Shaver, a world expert on this topic, writes "What a delight! Wallin has written an extremely insightful, broadly integrative, clinically clinically applicable, and highly engaging book. Keeping his personal and clinical experiences coherently in mind and using them as examples, he synthesizes recent literatures on attachment theory and research, mindfulness, mentalization, metacognition, nonverbal communication, intersubjectivity, and mechanisms of therapeutic change. The book moves deftly from clear analyses of contemporary theoretical issues to specific, well-described clinical techniques that can be used with particular clients; for example, those with a particular adult attachment pattern. The book identifies diverse theoretical and empirical advances that, in Wallin's skillful hands, fit together beautifully, deepening our understanding of the human mind, its relational context, and its transformation in psychotherapy."  Wow!  And fascinatingly, Wallin is making a rare visit to the UK in June - see the London conference details and also his more US based calendar.

And see tomorrow's blog post - "A good way of assessing attachment style across a variety of close relationships: the ECR-RS questionnaire" - for a very useful way of assessing & monitoring attachment across a variety of relationships, including between therapist and client.

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