PPRNet Clinical summary: Therapist Attachment Style and the Working Alliance

There is increasing interest in therapist factors that affect psychotherapy processes and outcomes, but not a lot of research on these topics. One therapist factor that has received some research attention is attachment style. Attachment refers to internal working models of relationships and emotion regulation rooted in early interactions with caregivers. Internal working models become codified in the implicit memory system over time and affect adult relationships and emotional experiences. Securely attached individuals tend to manage emotions well and are open to collaborative relationships. Anxiously attached individuals have problems with emotion regulation and conflicts in relationships. Avoidantly attached individuals have difficulty asking for help and experience distress when faced with emotional problems. One could speculate that therapists’ attachment style might affect their capacity to develop collaborative relationships with patients, which is the hallmark of a therapeutic alliance. In this systematic review, Marin-Cavestany and colleagues studied whether therapists’ attachment styles influence the assessment of the therapeutic alliance with patients. They found 23 studies (representing 354 patients), 12 of which were included in a quantitative meta-analysis. In a narrative review, they found that therapists with an insecure attachment (anxious or avoidant type) may have difficulty with establishing a solid therapeutic alliance with patients. In the quantitative meta-analysis, they found that attachment anxiety was negatively associated with the alliance when rated by the therapist (r = −0.31 [−0.38, −0.24]), but not when the alliance was rated by the patient (r = 0.04 [−0.16, 0.24]). In other words, therapists with higher attachment anxiety tend to rate their own alliance to patients lower.

Practice Implications

It is not surprising that therapists’ attachment might be related to their capacity to develop a therapeutic alliance since the alliance is based on developing a collaborative relationship with the patient. Although the research is limited at this time, with only a handful of studies, the findings point to a likelihood that therapists with a secure attachment have an advantage in creating an alliance. Attachment anxiety in the therapist may reduce their capacity to develop a collaborative experience with patients. Therapists can benefit from reflecting on their attachment styles, working on their own personal and emotional development, and improving their relational skills through professional consultations and personal therapy.

Marín-Cavestany, M., De la Cruz, M. Á., Durán, J. I., Stiles, B. J., Lahera, G., & Andrade-González, N. (2025). Influence of therapist attachment style on the working alliance in individual psychotherapy: A systematic review and meta-analysis. Clinical Psychology & Psychotherapy, 32(1), e70025. https://doi.org/10.1002/cpp.70025.