CLIENT ATTACHMENT TO THERAPIST, DEPTH OF IN-SESSION EXPLORATION, AND OBJECT RELATIONS IN BRIEF PSYCHOTHERAPY

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1 Psychotherapy: Theory, Research, Practice, Training Copyright 2005 by the Educational Publishing Foundation 2005, Vol. 42, No. 1, /05/$12.00 DOI: / CLIENT ATTACHMENT TO THERAPIST, DEPTH OF IN-SESSION EXPLORATION, AND OBJECT RELATIONS IN BRIEF PSYCHOTHERAPY BRENT MALLINCKRODT, MARY JO PORTER, AND DENNIS M. KIVLIGHAN JR. University of Missouri Columbia Two studies explored attachment in psychotherapy. In the 1st study, clients (N 38) in time-limited therapy completed the Experiences in Close Relationships Scale as a measure of adult attachment, the Client Attachment to Therapist Scale (CATS), Working Alliance Inventory (WAI), and measures of session depth and smoothness. Consistent with J. Bowlby s (1988) concept of a secure base promoting greater exploration, secure attachment to therapist was significantly associated with greater session depth and smoothness. Insecure adult attachment was associated with insecure therapeutic attachment. CATS subscales predicted unique variance in session experience not accounted for by the WAI alone. The 2nd study was a new analysis of data originally reported by B. Mallinckrodt, D. L. Gantt, and H. M. Coble (1995). Among women clients (N 44) who completed the CATS, WAI, and the Bell Object Relations and Reality Testing Inventory, 2 CATS subscales predicted unique variance in object relations deficits not accounted for by the WAI alone. Brent Mallinckrodt, Mary Jo Porter, and Dennis M. Kivlighan Jr., Department of Educational, School, and Counseling Psychology, University of Missouri Columbia. Correspondence regarding this article should be addressed to Brent Mallinckrodt, PhD, University of Missouri, 16 Hill Hall, Columbia, MO mallinckrodtb@missouri.edu A growing body of evidence suggests that clients adult attachment style may have an important influence on the psychotherapy relationship (for reviews, see Mallinckrodt, 2000; Meyer & Pilkonis, 2001). However, the recent American Psychological Association Division 29 Task Force on psychotherapy relationships concluded that evidence is as yet insufficient to make a clear judgment about whether customizing the therapy relationship to account for client attachment style could make a positive contribution to treatment outcomes (Ackerman et al., 2001, p. 496). In response to the Task Force s call for more research, we explored the following three research questions, which we felt were useful next steps in the application of attachment theory to psychotherapy research: (a) From the standpoint of Bowlby s (1988) concept of secure base for exploration, is greater security of a client s attachment to his or her therapist associated with more extensive in-session therapeutic exploration? (b) How closely does the attachment relationship between client and therapist mirror aspects of the client s other close attachment relationships? (c) Can the construct of client attachment to therapist explain something unique about the psychotherapy process or the client that is not explained by the working alliance? Attachment as a Secure Base for Exploration Bowlby (1969, 1973) held that from an ethological perspective, the attachment of young children to their caregivers involves two behavioral systems a proximity-seeking attachment system and an exploratory system. The two systems are complementary in that as one becomes activated, the other is automatically deactivated. Because human offspring are born relatively helpless and this altricial period continues for several years, infant caregiver proximity is crucial for survival. Among the young of our distant ancestors, proximity to caregivers offered greater access to food, 85

2 Mallinckrodt, Porter, and Kivlighan warmth, and protection from predators. Given this heritage, it is not surprising that a wide variety of cues serve to activate proximityseeking behavior in modern human caregivers and children. When a child is hungry, weary, or ill or when either the caregiver or child senses danger, each will usually cease all other behaviors and seek one another, with growing intensity and anxiety, until contact is reestablished. Typically, the child will not return to exploration behavior until a sufficient sense of security has been reestablished (Sroufe & Waters, 1977). Although exploration and proximity-seeking are complementary systems, because of the survival value of proximity, the latter system predominates. Consequently, many infants and young children quickly terminate exploratory behavior when they experience even mild levels of anxiety. However, in Ainsworth s famous strange situation laboratory protocol, infants who were securely attached to their caregivers, compared with those whose attachment was more anxious, were able to explore a novel play environment and overcome the initial insecurity posed by unfamiliar surroundings (Ainsworth, Blehar, Waters, & Wall, 1978). Thus, a crucial point for the current study is that a child s ability to sustain exploratory behavior depends not only on relative freedom from threats in the immediate environment but also on having attained a level of secure attachment with caregivers that provides a secure base from which the child can explore. This sense of secure base allows children to regulate anxiety associated with exploring a novel physical (and later social) environment. However, children who experience caregivers as relatively unresponsive or abusive experience anxiety in novel situations that they are unable to regulate (Egeland & Sroufe, 1981; Hazan & Shaver, 1994). Bowlby (1988) and Ainsworth (1990) maintained that the concept of a secure base for exploration was applicable through all stages of development as Bowlby stated, from the cradle to the grave (p. 163). Longitudinal research has finally begun to examine the continuity of attachment patterns from early childhood through late adolescence and the early adult years (e.g., Hamilton, 2000; Waters, Merrick, Treboux, Crowell, & Albersheim, 2000). A recent metaanalysis of longitudinal data concluded that attachment security is moderately stable across the first 19 years of life (Fraley, 2002, p. 123). Other researchers have concluded that the likelihood of secure attachment in infancy being maintained through adulthood depends on the stability of the family environment (Waters, Weinfield, & Hamilton, 2000). Without directly addressing the issue of infant adult continuity, research has shown that adult secure attachment is associated with exploration, operationalized in the form of a mastery-approach orientation toward goals and high need for achievement (Elliot & Reis, 2003). In contrast, insecure adult attachment in this study was associated with high fear of failure and a performance-avoidance orientation toward goals. Attachment theorists suggest that securely attached adults, similar to secure children, are more open to exploration and better able to regulate anxiety in novel social situations (Bartholomew & Horowitz, 1991; Hazan & Shaver, 1994; Lopez & Brennan, 2000). Persons with relatively secure adult attachment demonstrate greater willingness to reveal themselves through personal selfdisclosure (Mikulincer & Nachshon, 1991). In one of his last writings, Bowlby (1988) speculated that the psychotherapy relationship incorporates important features of attachment and that the therapist may serve as a secure base for clients to explore the internal landscape of their own emotional and interpersonal functioning. Since the time of Bowlby s suggestion, a growing number of empirical studies have applied attachment theory to gain a better understanding of psychotherapy processes. For example, securely attached adults in therapy, compared with insecurely attached clients, were found to recall more coherent relationship narratives, both positive and negative, and were better able to integrate and interpret past experiences (Buchheim & Mergenthaler, 2000). Secure attachment appears to be necessary for adults to develop the cognitive capacity of self-reflective mentalization that permits introspection, metacognition, and cognitive appraisal of one s interpersonal relationships all skills that facilitate the depth of exploration required in successful insight-oriented therapy (Fonagy, Gergely, Jurist, & Target, 2002). Some writers have speculated that clients who develop a secure attachment to their therapist may be more able than other clients to use the psychotherapy relationship as a secure base for exploration of past emotional experiences related to their presenting problem (Della Selva, 1993; Farber, Lippert, & Nevas, 1995; Mallinckrodt, 2000; Sable, 1997). 86

3 Client Attachment to Therapist The extent of infant exploration in the strange situation protocol can be measured in terms of physical distance that the child travels away from a stationary caregiver. To measure the extent of exploration in psychotherapy, we chose the Depth and Smoothness subscales of the Session Evaluation Questionnaire (SEQ; Stiles, Shapiro, & Firth-Cozens, 1990; Stiles & Snow, 1984a, 1984b). This operationalization reflects our belief that the concept of a psychotherapeutic secure base is best represented by a client s experience of exploration in relative safety, that is, sessions that combine both the intensive inner examination characteristic of the SEQ Depth scale, with the moderation of clients anxiety, and feelings of relative safety and comfort characteristic of the SEQ Smooth scale. Sessions that are deep but not smooth may be fraught with too much anxiety to be ultimately productive and have been described as heavy going ; sessions that are smooth but lack depth may be superficial and have been described as merely coasting, whereas sessions that combine both depth and smoothness may be among the most productive and have been described as smooth sailing, to use a nautical metaphor (Orlinsky & Howard, 1977, as cited in Stiles et al., 1994, p. 175). Thus, the first purpose of this study was to test the hypothesis that clients secure attachment to therapist is associated with deeper and smoother in-session client experience in the middle stages (i.e., 4th 8th session) of time-limited therapy. We reasoned that at least four sessions are required to form a reasonably secure attachment. Previous research suggests that SEQ Depth between 4 and 8 sessions of time-limited therapy is a significant predictor of eventual outcome (Mallinckrodt, 1993). This middle interval may also be a critical period that begins to differentiate the therapy process of clients who have established an early secure attachment with their therapist from those who have not. Attachment to Significant Others and to Therapists There is a growing consensus among researchers that adult attachment is best conceived along continuous dimensions rather than discrete qualitative categories (e.g., Bartholomew & Horowitz, 1991). Sophisticated quantitative methods have failed to find evidence of sharp distinctions between proposed categories (Fraley & Waller, 1998). In contrast, a factor analysis of over 1,000 participants, who completed more than 300 items drawn from every English language self-report adult attachment measure available at the time, suggested that two relatively orthogonal dimensions provide a very good description of the data (Brennan, Clark, & Shaver, 1998). The Anxiety dimension involves fear of rejection, preoccupation with abandonment, and negative feelings prompted by a partner s perceived lack of responsiveness. The Avoidance dimension taps fear of intimacy and discomfort with getting close to others. Attachment security is represented by relatively low scores on measures of both dimensions. A number of recent studies have linked attachment avoidance and anxiety to distinct profiles of psychological distress and maladaptive interpersonal functioning, together with variables that appear to mediate this attachment distress links, including problem solving (Wei, Heppner, & Mallinckrodt, 2003); perfectionism (Wei, Mallinckrodt, Russell, & Abraham, 2004); and social competencies (Mallinckrodt & Wei, in press). Following Bowlby s (1988) contention that psychotherapy incorporates important features of an attachment relationship and drawing primarily from the concept of transference, several writers have speculated that key features of a client s adult attachment pattern influence the type of attachment formed with their therapist (e.g., Fonagy et al., 2002; Mallinckrodt, 2000; Sable, 1997; Slade, 1999; Szajnberg & Crittenden, 1997). However, there have been surprisingly few empirical studies of this question. Mallinckrodt et al. (1995) asked a panel of experienced therapists to generate items they believed would tap attachment-related aspects of the psychotherapy relationship. A factor analysis of the responses from more than 130 clients to these items identified the following three dimensions: (a) Secure clients perceive their therapist as a comforting presence who is responsive, sensitive, and emotionally available; (b) Avoidant Fearful clients are reluctant to make personal disclosures, feel threatened or humiliated in sessions, and suspect that their therapist is disapproving and likely to be rejecting if displeased; and (c) Preoccupied Merger clients long for more contact and to be at one with their therapist, wish to expand the relationship beyond the bounds of therapy, and wish to be their therapist s favorite client. These dimensions are assessed by the 87

4 Mallinckrodt, Porter, and Kivlighan 36-item, self-report Client Attachment to Therapist Scale (CATS). In developing the CATS, Mallinckrodt et al. (1995) reported that only one of its three subscales (Preoccupied Merger) was significantly correlated with only one of the three subscales (Depend) of Collins and Read s (1990) Adult Attachment Scale (AAS). However, Mallinckrodt, King, and Coble (1998) reported that each of the three CATS subscales was significantly correlated with clients reports of dysfunctional structure in their family of origin. Thus, the small number of available studies are mixed with regard to how clients attachments with significant others might be manifested in psychotherapy. To extend this research, we explored, as the second purpose of the current study, associations between clients adult romantic attachment patterns and the attachment they form to their therapist. Are Attachment to Therapist and Working Alliance Different Constructs? A growing number of studies have investigated links between clients adult attachment and quality of the working alliance. For example, Satterfield and Lyddon (1995) found a significant relationship between working alliance and the Depend subscale of the AAS (Collins & Read, 1990). Kivlighan, Patton, and Foote (1998) found that both the Depend and the Close AAS subscales were related to client working alliance. Kanninen, Salo, and Punamaki (2000) found that patterns of working alliance waxing and waning over the course of therapy varied according to clients adult attachment patterns. Eames and Roth (2000) found that fearful attachment was associated with lower working alliance ratings (of both therapist and client), whereas secure attachment was associated with higher therapist and client working alliance. If adult romantic attachment appears to be associated with both client attachment to therapist and working alliance, questions then naturally arise about the link between working alliance and client attachment to therapist in effect, completing the third side of a conceptual triangle. Mallinckrodt et al. (1995) reported high correlations (rs.77) between the Secure subscale of the CATS and subscales of the Working Alliance Inventory (WAI). Correlations between the Avoidant Fearful CATS subscale and WAI subscales ranged from.57 to.71, whereas correlations with the Preoccupied Merger subscale ranged from.09 to.19. Given such high correlations for two CATS subscales with the WAI, it is reasonable to question the discriminant validity of at least some of the CATS subscales (Meyer & Pilkonis, 2001). In other words, conceptually, is the construct of client attachment to therapist different in any meaningful way from the construct of working alliance, and, if so, can knowing about a client s attachment to his or her therapist tell us something important about the client or psychotherapy process beyond information available from assessments of the working alliance? These two constructs overlap in that the Bond aspect of the alliance embodies trust, mutual respect, and an emotional alignment between therapist and client (Gelso & Carter, 1994), and secure attachment involves experiencing the therapist as responsive, sensitive, understanding, and emotionally available; [and] feeling hopeful and comforted (Mallinckrodt et al., 1995, p. 310). However, the constructs differ in that secure attachment involves explicitly feeling encouraged to explore frightening or troubling events (Mallinckrodt et al., 1995, p. 310) in therapy, whereas none of thee three WAI subscales explicitly tap this conception of inner exploration. Thus, because secure attachment is conceptually more closely related to in-session exploration than working alliance, the third purpose of this study was to examine the discriminant validity of the CATS by testing the hypothesis that the Secure subscale would predict significantly more unique variance in session depth and smoothness than the WAI. Finally, through reviewing literature for this study, we discovered a further opportunity to differentiate the constructs of attachment to therapist and working alliance. In developing the CATS, Mallinckrodt et al. (1995) also administered to clients the Working Alliance Inventory and a measure of object relations the Bell Object Relations and Reality Testing Inventory (BORRTI; Bell, 1995a). Unfortunately, Mallinckrodt et al. reported correlations only between the BORRTI and CATS but not between the BORRTI and Working Alliance Inventory. Previous research suggests that clients object relations capacity is significantly associated with working alliance (Piper, Joyce, McCallum, Azim, & Ogrodniczuk, 2001). However, on conceptual grounds, it could be argued that client attachment to therapist should be even more closely associated with a 88

5 Client Attachment to Therapist client s object relations capacity than working alliance. Because one of the BORRTI subscales is specifically designed to measure insecure attachment as a component of object relations, we analyzed data from Mallinckrodt et al. to further examine the discriminative validity of the CATS. Specifically, our fourth hypothesis held that the CATS subscales would account for a significant unique proportion of variance in measures of object relations (including insecure attachment ) beyond the variance accounted for by the WAI. Overall Method Two independent samples were used in this study: a sample of clients solicited specifically for this project (Study 1) and an archival sample (Study 2), consisting of part of the data reported originally by Mallinckrodt et al. (1995). Study 1 Method Participants Clients were recruited for the current study from the counseling center of a large, Midwestern, public university. A total of 38 clients provided usable data. Of these, 14 (37%) were men and 24 (67%) were women. Their mean age was years (SD 9.76, range years). In terms of ethnic identification, 32 (89%) indicated White, Non-Hispanic, whereas 1 each (3%) indicated African American, Hispanic, Asian American, and International Student, and 2 (6%) indicated more than one ethnic group. At the time of data collection, all clients had completed 4 8 sessions (M 5.69, SD 0.93), but because of the center s requirement that surveys remain anonymous, we had no way of knowing how many sessions were eventually completed. However, the center s policy routinely assigns clients to receive 12 sessions. Thus, Sessions 4 8 represented the middle phase of counseling for most clients. The study was described for clients as intended to increase understanding of the counseling process and how your relationship with your counselor contributes to the effectiveness of counseling. Incentives of a $5.00 university bookstore gift certificate were offered for completion of the research packet. Instruments Experiences in Close Relationships Scale (ECRS). The ECRS (Brennan et al., 1998) was developed from survey responses of more than 1,000 undergraduates to over 300 items drawn from all the extant self-report measures of adult attachment. Factor analyses identified two orthogonal dimensions, consisting of 18 items each. The Anxiety subscale taps fears of being abandoned by one s partner, whereas the Avoidance subscale taps fears of intimacy and emotional closeness. Respondents are directed to complete the ECRS in terms of their opinions about romantic relationships in general, not how a particular relationship is experienced at the moment. The ECRS uses a 7-point Likert-type response scale (1 disagree strongly, 4 neutral/mixed, 7 agree strongly). Brennan et al. (1998) reported internal reliability (coefficient alpha) of.91 and.94, respectively, for the Anxiety and Avoidance subscales. Brennan, Shaver, and Clark (2000) reported retest reliabilities (3-week interval) of.70 for both subscales. Evidence of validity was provided by significant correlations with other measures of adult attachment, with measures of preferences about sexual behavior and touch (Brennan et al., 1998), as well as interpersonal problems and core relationship conflicts (Mallinckrodt & Wei, in press). Internal reliabilities (coefficient alpha) in this study for the Anxiety and Avoidance subscales were.91 and.93, respectively. Client Attachment to Therapist Scale (CATS). The CATS (Mallinckrodt et al., 1995) was developed to assess the psychotherapy relationship from the perspective of attachment theory. Factor analysis of an initial pool of 100 items identified 36 that formed three subscales. The Secure subscale (14 items) includes items that assess clients feeling encouraged to explore frightening or troubling material in therapy and perceptions of the therapist as a responsive, sensitive, emotionally available, and comforting presence. The Avoidant Fearful subscale (12 items) assesses suspicion that the therapist is disapproving and likely to be rejecting if displeased, reluctance to make personal disclosures, and feeling threatened or humiliated in the sessions. The Preoccupied Merger subscale (10 items) assesses longing for more contact and to be at one with the therapist, wishing to expand the relationship beyond the bounds of therapy, and having a preoccupation with the therapist and the therapist s other 89

6 Mallinckrodt, Porter, and Kivlighan clients. Clients respond using a 6-point scale ranging from strongly agree (1) to strongly disagree (6). For all three CATS subscales, internal consistency (coefficient alpha) was greater than.63, and retest reliability (2 4-week interval) was greater than.72. Evidence of validity was provided by significant correlations of CATS subscale scores with measures of adult attachment, working alliance, and object relations. In the current study, internal reliabilities (coefficient alpha) for the Secure, Avoidant Fearful, and Preoccupied Merger subscales were.78,.83, and.82, respectively. Working Alliance Inventory (WAI). The WAI (Horvath & Greenberg, 1989) is a 36-item selfreport measure that uses a 7-point fully anchored response scale (1 never, 7 always). Parallel 36-item forms are used for clients and counselors, but only the client form was used in the present study. The WAI is based on Bordin s (1979) model of the working alliance and consists of three subscales to assess (a) the emotional bond of trust and rapport between counselor and client, (b) agreement about the overall goals of treatment, and (c) agreement about the tasks relevant for achieving these goals. Good construct validity has been established using multitrait multimethod analyses. Evidence of concurrent and predictive validity is provided by significant correlations with other counseling relationship measures and with measures of therapeutic outcome (Horvath & Greenberg, 1989; Horvath & Symonds, 1991). In the current study, internal reliabilities (coefficient alpha) were.75,.89, and.82 for the Bond, Tasks, and Goals subscales, respectively. Session Evaluation Questionnaire (SEQ). The SEQ (Stiles & Snow, 1984a, 1984b) consists of bipolar adjective scales in a 7-point semantic differential format. The SEQ measures clients perceptions of a given psychotherapy session along two dimensions related to content and flow (Depth and Smoothness) and two dimensions of postsession client mood (Positivity and Arousal). The Depth subscale assesses perceptions of a therapy session s value and power, whereas Smoothness refers to a session s comfort, relaxation, and pleasantness. Positivity involves postsession feelings of confidence, clarity, and happiness, whereas Arousal refers to feelings of activity and excitement as opposed to calmness and quietness. Note that only 19 of the 24 items are scored to form the subscales of Depth (five items), Smoothness (five items), Positivity (five items), and Arousal (four items). Although all the items were administered, only the Depth and Smoothness data were used in this study. The authors have conducted extensive factor analyses with large samples of clients and report good internal consistency for the four dimensions, with reported coefficient alphas ranging from.78 to.91 (Stiles & Snow, 1984a, 1984b). They also reported that scores on Depth and Smoothness subscales were relatively independent of each other, whereas Positivity and Arousal were moderately correlated. In the current study, internal reliabilities (coefficient alpha) were.82 and.85 for the Depth and Smoothness subscales, respectively. The SEQ has been used in numerous studies of psychotherapy process and outcome (e.g., Reynolds et al., 1996; Stiles et al., 1990). Client evaluations on the SEQ have been associated with working alliance (Kivlighan, Angelone, & Swafford, 1991; Mallinckrodt, 1993) and the likelihood of premature termination (Tryon, 1990). Procedure To solicit clients, we placed flyers in the waiting areas of the counseling center, directing those interested in participating to inquire at the front desk. Clients who had completed 3 7 sessions were given a packet and were directed to complete the survey immediately after their next session (i.e., the 4th 8th). The informed consent document stated that participation was completely voluntary and could be ended at any time without penalty. Clients were directed to complete the survey immediately after their session and return it to the receptionist, who then immediately issued the $5 gift certificate incentive. Given that clients would continue in therapy after data had been collected, staff members of the counseling center responsible for the protection of research participants insisted that client identifying information in any form not be collected. Thus, clients had a firm assurance that their therapist could never identify the ratings they provided, and therapists could be assured that members of the research team could never match a particular client s ratings with a particular therapist. However, this procedure prevented us from collecting information that could be used to provide a general characterization of the sample in terms of duration and nature of the therapy, the therapists, and the severity of clients presenting problems. We can report that therapists at this 90

7 Client Attachment to Therapist center practice from a wide range of theoretical orientations and this center employed practicum students at the master s and doctoral level, interns in an APA-accredited internship, and senior staff who were licensed psychologists. Study 2 Method: Archival Data Participants and Procedure We obtained data from 47 clients who completed the WAI, the CATS, and the BORRTI in the study reported by Mallinckrodt et al. (1995). Because only three clients in this sample were men, only data from the 44 female clients were retained for analyses. (We reasoned that it was better to create a single-sex sample that offered greater generalizability for women clients than to retain a sample with such a marked imbalance of both sexes.) Of these 44 clients, 21 had been seen at a University Counseling Center, and 23 had been seen at a counseling psychology program s in-house training clinic both in Eugene, Oregon. The clients mean age was years (SD 11.28, range 19 62). At the time of data collection, they had completed a mean of 9.89 sessions (SD 4.15, range 5 20). Regarding ethnic identification, 38 (87%) indicated White, Non-Hispanic, 1 (2%) indicated Native American, and 5 (11%) did not respond to this item. Clients were also guaranteed anonymity. Thus, information about their therapy, presenting problem, and therapist was not available. We do know that therapists at the counseling center represented a diversity of orientations, although the training clinic emphasized an interpersonal approach (Teyber, 1992) with students. Instruments In addition to the WAI and CATS described previously, clients also completed the BORRTI (Bell, 1995a). The BORRTI is a self-report measure of ego functioning and object relations. Mallinckrodt et al. (1995) used only the 45 true false items of the Object Relations domain and not the 45 Reality Testing items. Four subscales measure the following object relations deficits: (a) Alienation a lack of basic trust in relationships, inability to attain closeness, and hopelessness about achieving stable and satisfying levels of intimacy; (b) Insecure Attachment painful and awkward interpersonal relations, sensitivity to rejection, and excessive concerns about being liked and accepted; (c) Egocentricity mistrust of the motivations of others, sense that others exist only in relation to oneself, and others are manipulated for one s own aims; and (d) Social Incompetence shyness, uncertainty about how to interact with the opposite sex, and inability to make friends. Bell (1995a) reported high factorial stability for these four subscales, with internal consistency ranging from.78 to.90. The BORRTI has demonstrated significant discriminant validity in tests comparing adult volunteers with patients diagnosed with borderline personality disorder, major affective disorder, and schizophrenia (Bell, 1995a). Note that in 1995, the BORRTI was in the final stages of prepublication development and Mallinckrodt et al. (1995) used a simplified scoring method that has since been supplanted. For the present study, raw scores were input into the computerized scoring program (BORRTI Version 2.013; Bell, 1995b), which applies a proprietary method of item weighting, together with updated norms, to produce output in the form of T scores for each subscale. Results Study 1 In the current study, a composite Session Exploration Index was calculated by adding standardized SEQ Depth and Smoothness subscale scores. This index embodied the concept that both Depth and Smoothness are required elements for the kind of session exploration most likely to be facilitated when the therapist serves as a secure base. (The composite also reduced by half the number of statistical analyses needed to test our first 2 hypotheses.) Means, standard deviations, and correlations among the variables measured in Study 1 are shown in Table 1. Although Brennan et al. (1998) did not report ECRS norms, Mallinckrodt and Wei (in press) have reported means for a sample of 430 undergraduates. Using this data (Anxiety: M 3.71, SD 1.16; Avoidance: M 2.89, SD 1.18), we found that clients in our sample reported significantly more Anxiety, t(466) 3.15, p.01, and significantly more Avoidance, t(466) 1.97, p.05, in their adult attachments than typical undergraduates from the same university. Our first hypothesis held that secure client attachment to 91

8 Mallinckrodt, Porter, and Kivlighan TABLE 1. Study 1 Correlations of Attachment With Working Alliance and Session Evaluation Measure M SD Adult Attachment (ECRS) Client Attachment to Therapist Scale Anxiety Avoidance Secure Avoidant Fearful Preoccupied Merger Session Evaluation Questionnaire Depth **.40*.28 Smoothness **.56**.05 Exploration a **.59**.11 Adult Attachment (ECRS) Anxiety Avoidance *.02 Working Alliance Inventory Total *.24.69**.62**.13 Bond **.57**.11 Task *.21.69**.63**.11 Goal *.20.62**.55**.16 Client Attachment to Therapist Scale Secure **.07 Avoidant Fearful Preoccupied Merger Note. N 38. ECRS Experiences in Close Relationships Scale. a Exploration standardized Session Evaluation Questionnaire Depth standardized Session Evaluation Questionnaire Smoothness. *p.05. **p.01. the therapist would be associated with more extensive in-session exploration. The third line of Table 1 provides relatively strong support for this hypothesis. Secure Attachment to therapist was positively associated with Exploration (r.62, p.01), whereas Avoidant Fearful (i.e., insecure) attachment to therapist was strongly negatively associated with Exploration (r.59, p.01). The second purpose of this study was to explore associations between adult attachment and client attachment to therapist. The next two rows of Table 1 show that adult attachment Avoidance was positively associated with Avoidant Fearful attachment to therapist. Because of the small sample size, the correlations of Anxiety and Avoidance with Secure Attachment to therapist (r.31 and r.29, respectively) were not statistically significant (ps.08), but these relationships are noteworthy as possible targets for future research. Regarding working alliance, adult attachment Anxiety was negatively related to the Task and Goals subscales, but not with the Bond aspect of the alliance. Statistical power for these analyses to detect a moderate effect size (population r.30), given a sample of N 38 and two-tailed tests (.05), was.47. The third purpose of this study was to investigate the discriminative validity of the CATS. A hierarchical multiple regression analysis was conducted with session exploration (depth smoothness) as the criterion variable. In the first version of this analysis, for Step 1, total WAI scores were entered and accounted for a significant proportion of the variance, R 2.33, p.01. In the second step, a block of three predictor variables was entered consisting of the CATS Secure, Avoidant Fearful, and Preoccupied Merger subscales. Table 2 and Table 3 show that these variables entered in the second step of Analysis A produced a significant increment in R 2 ( R 2.17, p.05). When the order of these two steps was reversed in Analysis B, entering WAI scores in the second step after CATS subscales, total WAI did not predict a significant increment in R 2 ( R 2.03, ns). These findings support the second hypothesis and suggest that the CATS subscales account for a significant proportion of variance in psychotherapy exploration not accounted for by total WAI score, whereas total WAI does not account for a significant unique proportion of variance in exploration after accounting for the three CATS subscales. (This hierarchical regression analysis was repeated using the Bond, Task, and Goal WAI 92

9 Client Attachment to Therapist TABLE 2. Study 1 Multiple Regression Analyses Predicting Session Exploration From Working Alliance and Client Attachment to Therapist Step/variable entered R 2 Adjusted R 2 R 2 F dfs Analysis A (WAI first, then CATS) Step 1 (Total WAI) ** 1, 36 Step 2 (CATS subscales) * 3, 33 Analysis B (CATS first, then WAI) Step 1 (CATS subscales) ** 3, 34 Step 2 (Total WAI) , 33 Note. N 38. Criterion variable was session exploration, calculated as standardized SEQ Depth standardized SEQ Smoothness. WAI Working Alliance Inventory; CATS Client Attachment to Therapist Scale; SEQ Session Evaluation Questionnaire. *p.05. **p.01. subscales in place of total WAI scores. The findings were essentially identical.) Note that the standardized beta weights for the final model shown in Table 3 reveal that when taken together, none of the four variables was a significant unique predictor of session exploration. One reason for these findings may be the degree of variance shared among two or more of the CATS subscales. To clarify these findings, we performed three partial regression analyses to examine the association between in-session exploration and we examined the CATS subscales individually, controlling for the variance in exploration accounted for by working alliance. Significant associations were found between exploration and the CATS Secure subscale (r part.37, p.05), the Avoidant Fearful subscale (r part.36, p.05), but not the Preoccupied Merger subscale (r part.23, ns). Study 2 A second comparison of the CATS and WAI was conducted with a new analysis of data originally collected by Mallinckrodt et al. (1995). Means, standard deviations, and bivariate correlations for the variables in this sample are shown in Table 4. Two components of object relations were positively associated with Avoidant Fearful TABLE 3. Final Regression Model Statistics Statistic B SE B Total WAI CATS Secure CATS Avoidant Fearful CATS Preoccupied Merger Note. N 38. WAI Working Alliance Inventory; CATS Client Attachment to Therapist Scale. attachment to therapist, Alienation (r.46, p.01), and Social Incompetence (r.38, p.01). Social Incompetence was also significantly negatively associated with total working alliance and working alliance Task. Object relations Insecure Attachment was also negatively associated with the working alliance Task subscale. Thus, Table 4 shows that three of the four components of object relations deficits (all but Egocentricity) were negatively associated with one or more aspects of the psychotherapy relationship. Statistical power for these analyses to detect a moderate effect size (population r.30), given a sample of N 44 and two-tailed tests (.05), was.53. (Note that although Mallinckrodt et al. also reported correlations between BORRTI subscales and CATS subscales, findings in Table 4 do not duplicate the earlier results because we used the proprietary item-weighting scoring method for the BORRTI developed since the earlier study. Associations between BORRTI subscales and WAI subscales were not reported by Mallinckrodt et al. and are new to this analysis.) Note the high correlations between components of working alliance and the first 2 subscales of the CATS shown in Table 4. Understandably, correlations of this magnitude prompted other researchers to question whether the CATS measures something different from the WAI (Meyer & Pilkonis, 2001). To put this question to a further empirical test, we proposed in our fourth hypothesis that CATS subscales would account for a unique proportion of variance in object relations components (especially Insecure Attachment) beyond the proportion accounted for by working alliance. Four multiple regression analyses were conducted, each with a different BORRTI subscale as its criterion variable. The four predictor variables were WAI 93

10 Mallinckrodt, Porter, and Kivlighan TABLE 4. Study 2 Correlations Between Object Relations, Client Attachment to Therapist, and Working Alliance Measure M SD Client Attachment to Therapist Scale Working Alliance Inventory Sec Avd Pre Total Bond Task Goal Bell Object Relations and Reality Testing Inventory Alienation ** Insecure Attach **.22 Egocentricity Social Incompetence *.38**.13.32*.27.38*.23 Working Alliance Inventory Total **.56**.12.85**.92**.94** Bond **.57**.14.66**.70** Task **.55**.04.82** Goal **.41**.16 Client Attachment to Therapist Scale Secure **.16 Avoidant Preoccupied Note. N 44. Sec Secure; Avd Avoidant Fearful; Pre Preoccupied Merger; Attach. Attachment. *p.05. **p.01. total scale scores and the three CATS subscale scores. Table 5 shows that two standardized beta weights were statistically significant, and in both cases, these were CATS subscales: the Avoidant Fearful subscale in predicting Alienation and the Preoccupied Merger subscale in predicting BORRTI Insecure Attachment. Discussion The conceptual foundation for this study was Bowlby s (1988) attachment theory construct of secure base for exploration. Drawing from observational studies, Bowlby concluded that developing children first use the physical presence and TABLE 5. Study 2 Multiple Regression Analyses Predicting Object Relations From Working Alliance and Client Attachment to Therapist Variable R 2 Adjusted R 2 F(4, 39) B SE B Analysis 1: Criterion Alienation * Total WAI CATS Secure CATS Avoidant Fearful ** CATS Preoccupied Merger Analysis 2: Criterion Insecure Atch Total WAI CATS Secure CATS Avoidant Fearful CATS Preoccupied Merger * Analysis 3: Criterion Egocentricity Total WAI CATS Secure CATS Avoidant Fearful CATS Preoccupied Merger Analysis 4: Criterion Social Inc Total WAI CATS Secure CATS Avoidant Fearful CATS Preoccupied Merger Note. N 37. WAI Working Alliance Inventory; CATS Client Attachment to Therapist Scale; Insecure Atch Insecure Attachment; Social Inc Social Incompetence. p.08. *p.05. **p

11 Client Attachment to Therapist later the internalized mental representation of attachment figures to regulate the anxiety inherent in exploring the environment. Exploration is abruptly terminated and proximity seeking is triggered when a child s anxiety rises above a critical threshold. For the human species, this hierarchy of the two behavioral systems was essential for the survival of relatively helpless offspring and may well be hardwired into our biological makeup. A child s secure attachment with caregivers facilitates more effective regulation of anxiety and thus permits a wider range of exploration. Bowlby believed that a transformed version of this process persists throughout life. Adults with internalized positive working models of self and others enjoy relatively greater freedom from anxiety in novel situations. Consequently, they explore their environment to a greater extent than adults whose insecure attachments impose a lower threshold of limiting anxiety. Bowlby further speculated that a secure attachment between a client and a therapist allows the former to more completely explore troubling aspects of psychological experience. Although many writers have found Bowlby s ideas intuitively appealing, and many have elaborated on how the secure base construct applies in psychotherapy (e.g., Della Selva, 1993; Farber et al., 1995; Mallinckrodt, 2000; Sable, 1997), we could find no previous study that directly tested this relationship. Undertaking such a test was the first purpose of this study. Among the more than 100 items generated by the panel of expert therapists who assisted Mallinckrodt et al. (1995) in developing the CATS, several items were intended to explicitly tap the secure base aspect of psychotherapy attachment. Factor analyses identified 36 items for the final scale. Of the 12 items that compose the Secure subscale, at least 3 tap a client s perception of the therapist as a secure base: (a) My counselor is a comforting presence to me when I am upset, (b) My counselor helps me to look closely at the frightening or troubling things that have happened to me, and (c) I feel that somehow things will work out OK for me when I am with my counselor. Thus, we chose the CATS to assess clients perceptions of the therapist as a secure base for exploration. We originally planned to operationalize the extent of client exploration using the Experiencing Scale (Klein, Mathieu-Coughlan, & Kiesler, 1986). However, we could not secure permission from a sufficient number of therapists who would allow their sessions to be recorded for analysis. Consequently, we chose the Depth and Smoothness scales of the SEQ to operationalize a client s experience of therapeutic secure base, specifically, inner exploration combined with a sense of relative safety. We focused on the middle third of 12- session time-limited therapy, because we reasoned that in the first 3 sessions, a secure attachment to the therapist would not have sufficient time to develop, whereas by the 9th 12th sessions, clients with poor attachment or working alliance might no longer be in treatment. Findings of Study 1 offer strong support for the hypothesis that secure attachment of clients to their therapist is associated with client reports of deeper and smoother sessions. It also appears that Avoidant Fearful attachment is negatively associated with both SEQ Depth and Smoothness. The findings are consistent with Bowlby s (1988) contention that clients can use a secure attachment to their therapist as a secure base for psychological exploration. Other research suggests that many clients equate session smoothness with perceptions of safety (Stiles & Snow, 1984b). Although our study did not assess outcome, still other research suggests that depth and smoothness in time-limited therapy are related to positive outcomes (Mallinckrodt, 1993; Reynolds et al., 1996). By extension, these findings are at least consistent with a model in which secure attachment to therapist facilitates a sense of safety for in-session exploration, which in turn facilitates positive outcomes. Of course, these correlational findings do not provide conclusive evidence of causal relationships. Secure attachment to therapist was also strongly associated with ratings of positive working alliance in both studies reported in this article. Thus, it is also possible that therapeutic attachment security, with its attendant confidence that the therapist will be generally available despite an occasional empathic failure, may also help clients to weather the stresses of temporary working alliance ruptures (Kanninen et al., 2000; Safran & Muran, 2000). A recent study of clients who had been in treatment a median of 10 months reported that client ratings of more secure attachment to their therapist, measured with the CATS, were associated with therapists ratings of more negative client transference (Woodhouse, Schlosser, Crook, Ligiero, & Gelso, 2003). In interpreting these findings, Woodhouse et al. 95

12 Mallinckrodt, Porter, and Kivlighan speculated that secure therapeutic attachment offers clients a secure base for exploration and, at least in treatment of fairly long duration, also the opportunity to explore negative transference with their therapist. Our second hypothesis held that security or insecurities in a client s close romantic attachments would be mirrored in the psychotherapy relationship. Study 1 offers some support for this hypothesis although at a more equivocal level than the support obtained for the first hypothesis. Both anxiety and avoidance in romantic attachments were associated with Avoidant Fearful attachment to therapists. It is curious that these two different forms of insecurity in adult romantic relationships appeared to influence clients attachments to their therapist in much the same way. Because the Preoccupied Merger CATS subscale taps themes of dependency, it might be expected that scores would be positively correlated with anxieties about abandonment in romantic relationships. However, the correlation was not significant (r.26). Perhaps the association was not stronger because the CATS Preoccupied Merger subscale contains items that tap a poor sense of boundaries (e.g., I think about calling my counselor at home, I wish my counselor were not my counselor so that we could be friends ) that may not have been activated in the relatively high functioning clients included in our sample. Romantic attachment anxiety did exhibit an interesting pattern of negative associations with working alliance components. Table 1 shows that ECRS Anxiety was significantly negatively associated with the Tasks and Goals component of the alliance but not the Bond component. This pattern suggests that clients with high anxiety in romantic attachments may experience relatively more difficulty agreeing about the direction (i.e., tasks and goals) of therapy than forming an emotional bond with their therapist. Thus, taken together, the findings of this study that support the first 2 hypotheses join the growing body of research evidence suggesting that when it comes to the capacity to benefit from time-limited therapy, the rich get richer, and the poor get poorer (Luborsky et al., 1993). Our findings suggest that clients who begin therapy with greater psychological resources in the form of a capacity to quickly form a secure attachment to their therapist seem more willing than clients with insecure attachment to engage in deep exploration of their issues, form an interpersonal bond with their therapist, and collaborate on the goals and tasks of therapy. In contrast, clients with strong themes of avoidance or anxiety in their romantic relationships also tend to exhibit considerable avoidance in their therapeutic attachments, which also appears to involve reluctance to self-disclose in therapy, a tendency to mistrust the therapist, and strongly negative feelings about psychotherapy. Avoidant attachment to one s therapist is also associated with clients experiencing sessions as both shallow and rough. Findings of Study 1 are also congruent with a number of other studies that have linked problems in clients generalized adult attachment patterns with poor working alliance (e.g., Eames & Roth, 2000; Kanninen et al., 2000; Kivlighan et al., 1998; Mallinckrodt et al., 1995; Satterfield & Lyddon, 1995). Presumably, negative working models about self and others influence clients perceptions of the therapist and expectations of how the therapist will regard the client an influence that can be interpreted as transference (Kivlighan, 2002; Szajnberg & Crittenden, 1997). Transference of this type was also evident in an analysis of round robin data collected from interpersonal growth groups (Mallinckrodt & Chen, 2004). Group members with high ECRS Avoidance subscale scores exhibited a systematic bias toward seeing other group members as less friendly and less dominant than the same target members were viewed by perceivers with lower ECRS Avoidance. The last two hypotheses of this study explored the question of whether client attachment to therapist is a construct meaningfully different from working alliance. In Study 1, we found the same high level of correlations between the WAI and two CATS subscales (Secure and Avoidant Fearful) that have given rise to concerns about whether the constructs measured by these instruments are significantly different (Meyer & Pilkonis, 2001). Nevertheless, the analyses shown in Tables 2 and 5 indicate that, in direct comparisons with the WAI, some CATS subscales account for a unique proportion of variance in object relations deficits, as well as session depth and smoothness, beyond the variance accounted for by the WAI alone. Thus, we conclude that Hypotheses 3 and 4 are supported and that the CATS instrument can provide valuable information about counseling process (i.e., session depth and smoothness) or the client (i.e., object relations 96