The therapeutic alliance is one of the most researched concepts in psychotherapy. It refers to the collaborative agreement on the goals of therapy (what the patient wants to achieve), an agreement on the therapy tasks (what the therapist and patient do in therapy), and their relational bond. All three are necessary for a good therapeutic alliance. A meta-analysis of almost 300 studies have found that the alliance has a moderate but very reliable correlation with patient mental health outcomes (r = .28, p < .001). That is, if a patient and therapist can establish a good alliance early in therapy, the patient will likely experience greater reduction in symptoms. Identifying patient factors that might lead to poorer alliances can help clinicians work differently with these patients and repair alliance ruptures (disagreements on the tasks and goals of therapy or a weakening of the relational bond). In this meta-analysis, Notsu and colleagues were interested in assessing if patient attachment insecurity (i.e., attachment anxiety or attachment avoidance) was associated with a poorer therapeutic alliance with their therapists. Patients with greater attachment anxiety tend to be preoccupied with being close to attachment figures and are highly sensitive to signs of abandonment or separation. They may not easily voice disagreements for fear of creating more distance with therapists. On the other hand, those with greater attachment avoidance defensively keep their emotional distance and may disbelieve others’ good intentions. They may be less willing to consider shared agreements on tasks and goals of therapy with therapists, which in turn can hinder an emotional bond. In their systematic review, Notsu and colleagues found 33 studies representing 2,299 patients. The mean age of patients was 32.11 years (range = 21.6-45.2), and most were women and White. The studies also represented 582 clinicians, mostly White women with an average of 5 years of experience. The average effect size between attachment anxiety and alliance was r = -.09 (95% CI [-.15, -.03], p = .01), indicating a small but statistically significant association. The average effect size between attachment avoidance and alliance was r = -.13 (95% CI [-.19, -.07], p < .001), also indicating a small but statistically significant association. Greater patient attachment anxiety and attachment avoidance were each associated with poorer therapeutic alliance. The findings were robust, such that the effect sizes across studies had low to moderate variability.
Practice Implications
The findings suggest that the therapeutic alliance may be more difficult to maintain with patients high in attachment insecurity (attachment anxiety or attachment avoidance). Patients high in attachment anxiety may intensify their attachment behaviours, which could overwhelm some therapists. Patients high in attachment avoidance may be more detached when discussing emotional material, which may create distance from their therapist. Therapists should learn how to recognize and empathize with patients with different forms of attachment insecurity. This may help them to be optimally responsive, depending on the patient’s attachment style. Patients with greater attachment anxiety may need help to take a more distant and reflective stance regarding their emotions and their strong tendency to communicate their attachment needs. Patients with greater attachment avoidance may need more space and time to develop trust in a helping professional.
Notsu, H., Blansfield, R. E., Spina, D. S., & Levy, K. N. (2024). An updated meta-analysis of the relation between adult attachment style and working alliance. Psychotherapy Research, 1–14. https://doi.org/10.1080/10503307.2024.2370344
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