Interpersonal problems, attachment, and therapy
Today, I selected two articles that pertain to successful psychotherapy. First, Iovoli et al. (2024) published “The Relationship between Interpersonal Problems and Therapeutic Alliance in Psychotherapy: A three-level mixed-effects meta-analysis” in Psychotherapy. Here are the edited abstract and impact statements:
Psychotherapy is an interpersonal process of collaboration toward specified treatment goals. The therapeutic alliance is well established as an important factor of psychotherapeutic change. However, the experience of distress in social interactions, commonly referred to as interpersonal problems, might be interfering with the collaborative process during psychotherapy. This study systematically reviews the literature and obtains an estimate of the relationship between pretreatment interpersonal problems and the quality of the therapeutic alliance. Overall, 27 studies with 48 correlation coefficients were included in the final analysis. Due to the nested structure of the data, a three-level meta-analytic approach with a restricted maximum likelihood estimator was applied. Alliance assessment phase, alliance rater, alliance measure instrument, and treatment type were tested as potential moderators. Heterogeneity and publication bias test were performed. The meta-analysis showed a small, but significant negative relationship between interpersonal problems at the beginning of psychotherapy and subsequent therapeutic alliance (r = −.12, SE = .02, 95% CI [−.16, −.08], p< .001, d = −.27). Only alliance assessment phase accounted for significant variability. There were no indications for a substantial publication bias. Interpersonal problems of patients before psychotherapy are a robust predictor for lower therapeutic alliance quality, albeit a small effect size. Consequently, patients who experience interpersonal problems may face greater challenges in developing a strong alliance with their therapists, especially in early stages of the treatment.
Overall, there is a small but significant negative relationship between interpersonal problems at the beginning of psychotherapy and subsequent therapeutic alliance (r = −.12). Individuals with higher levels of interpersonal problems may face greater challenges in developing a strong therapeutic alliance with their therapists. However, these interpersonal problems also appear to present an opportunity for fostering a strong alliance. Future research ought to focus on how therapists adequately manage patients’ preexisting interpersonal problems.
This is one of those “makes perfect sense” studies, but I thought it was important as a duty to warn both for referring professionals and psychotherapists. The next study is similarly helpful.
Jennissen, Volz, Schauenburg & Dinger (2024) published “State and Trait Characteristics of Attachment as Predictors of Outcome in Inpatient Psychotherapy” in Psychotherapy. The edited abstract and impact statements follow:
Attachment has mostly been investigated as a stable characteristic of individuals, although theoretical considerations and recent empirical findings suggest that attachment styles are also subject to change. When attachment is investigated as a treatment factor in psychotherapy, state and trait characteristics need to be differentiated, as they warrant different conclusions. This study examined the trait- and statelike characteristics of attachment styles over the course of inpatient psychotherapy as predictors of treatment outcome. A total of N = 419 patients provided weekly measurements of attachment styles and symptoms for up to 8 weeks of inpatient psychotherapy. Data were analyzed in multilevel longitudinal models controlling for rolling admissions and weekly changes in group membership. Over the course of treatment, patients’ attachment styles became more secure and less fearful-avoidant. Trait attachment security as well as gains in attachment security predicted better outcomes, while trait preoccupied and fearful-avoidant attachment as well as increases in attachment preoccupation and anxiety predicted worse outcomes. Findings imply that attachment security may grow during a relatively short inpatient treatment period and both trait attachment styles as well as changes in attachment styles predict outcome.
Patients became more secure and less fearful-avoidant over the course of treatment. Patients who were generally more secure and those who became more securely attached from 1 week to another benefitted more from treatment. Both stable, traitlike aspects of attachment as well as changes in attachment during treatment affect how much patients benefit from treatment. Since the majority of attachment research investigated trait attachment, more research is needed on changes in attachment and how these affect psychotherapy process and outcome.
If you’ve been following the blog for a while, it’s clear that I like studies of attachment. What I love about this one is the reminder that attachment status can be either a state or a trait and the difference is important is therapy outcomes.