Die Bindungstheorie und ihre Relevanz für die Psychotherapie

Therapeutic alliance in individual adult psychotherapy: a systematic review of conceptualizations and measures for face-to-face- and online-psychotherapy

Background

The therapeutic alliance (TA) is a robust and pantheoretical predictor of treatment outcome in Face-to-Face- (F2F-) and Online-psychotherapy (Online-PT). Many authors have proposed several conceptualizations of TA, which are oftentimes operationalized. The resulting diversity of conceptualizations and measures is presented in this review.

Methods

We performed a three-parted literature search for self-report-instruments of TA in individual, voluntary F2F-PT with adults (1. utilization of past reviews, 2. systematic literature search yielding 5,205 articles, 3. reference lists). Analogously, we conducted a systematic literature search for instruments of TA in the Online-setting (yielding 200 articles). Additionally, we analyzed the content of the instruments qualitatively.

Results

A current overview of 48 instruments for measuring TA (46 for F2F-PT, 2 for Online-PT) including their conceptual backgrounds, characteristics and main content aspects is presented. Most instruments (n = 24) operationalize one or more theoretical conceptualizations of TA. Other instruments are adaptation/syntheses of existing measures (n = 14), based on literature searches (n = 3) or on an empirical survey (n = 3) and two instruments provide no conceptual background information. The content of the instruments mainly focused on the following aspects: 1. Self-disclosure and authenticity; 2. Agreement; 3. Active participation, motivation and compliance; 4. Trust and secure attachment; and 5. Considering needs/abilities/wishes of the patient. Additionally, a narrative review of various approaches to conceptualize TA is presented and linked to respective corresponding instruments.

Discussion

The broad variety of conceptualizations and measures of TA makes coherent research on TA difficult. There are conceptual challenges such as the role of attachment style in TA that remain to be clarified. The current conceptualizations and measures do not incorporate the practical experience and expertise of psychotherapists and patients sufficiently. A metatheoretical conceptualization and measure of TA based on an empirical survey of psychotherapists and patients could address these issues.

Attachment-specific speech patterns induce dysphoric mood changes in the listener as a function of individual differences in attachment characteristics and psychopathology

OBJECTIVES

Early childhood experiences influence cognitive-emotional development, with insecure attachment predisposing to potential psychopathologies. We investigated whether narratives containing attachment-specific speech patterns shape listeners' emotional responses and social intentions.

DESIGN

First, 149 healthy participants listened to three narratives characteristic for secure, insecure-preoccupied, and insecure-dismissing attachment. Following each narrative, the well-being and interpersonal reactivity as a particular aspect of emotional reactivity of the listener were assessed. Likewise, psychopathological aspects of personality were evaluated. A follow-up study compared 10 psychosomatic patients with a current depressive episode and/or personality disorder with distinct depressive symptoms and 10 age- and gender-matched healthy controls.

METHODS

Effects of narratives on listeners' mental state were tested with repeated-measures AN(C)OVA. Mediating effects in the listener (attachment characteristics in the context of personality traits) were explored. Narrative effects were compared between patients and controls.

RESULTS

Listening to insecure attachment narratives reduced well-being in controls. Nevertheless, tendency for social interaction was highest following the insecure-preoccupied narrative. Importantly, listeners' individual attachment characteristics mediated the relationship between well-being/interpersonal reactivity following the insecure-preoccupied narrative and levels of psychopathology. Furthermore, compared with healthy participants, patients showed higher emotional reactivity following exposure to the insecure-preoccupied narrative, represented by lower well-being and lower estimation of friendliness towards the narrator.

CONCLUSIONS

Exposure to attachment-specific speech patterns can result in dysphoric mood changes. Specifically, the insecure-preoccupied narrative influenced the listeners' emotional state, which was further mediated by the individual attachment patterns and psychopathological personality characteristics. This deepens the understanding of interpersonal processes, especially in psychotherapeutic settings.

PRACTITIONER POINTS

In clinical populations, insecure-preoccupied attachment has a high prevalence. In this study, listening to a narrative characteristic of insecure-preoccupied speech patterns resulted in reduced well-being in healthy listeners. Patients with depressive symptoms showed a higher emotional reactivity towards the insecure-preoccupied narrative compared to healthy controls. While working on (childhood) traumata, for example, in group therapy or inpatient settings, therapists should raise awareness to possible mood changes through discourse-conveyed attachment characteristics in listeners as a 'side effect'.

Mentalization as Mediator between Adult Attachment and Interpersonal Distress

BACKGROUND

The aim of this study was to investigate the mediating role of mentalization in the association between adult attachment and interpersonal problems.

METHODS

The sample consisted of 89 patients with different types of mental disorders who were at the beginning of treatment in one of two medical centers. Both mediational analysis and path analysis were used to test the model.

RESULTS

The proposed model revealed a good model fit. The data indicate that mentalization fully mediates the effect of attachment on interpersonal distress. Symptom severity proved to be a strong confounding variable that influenced all other variables and reduced existing effects.

CONCLUSION

We conclude that both mentalization and symptom distress are key components in the association of adult attachment and interpersonal problems. Therefore, we recommend research on integrative psychotherapy concepts rather than unilateral approaches.

Relationships between patients' attachment characteristics and views and use of psychiatric treatment

This study explored the influence of attachment on psychiatric treatment by considering attitudes towards and the use of psychotropic medication and psychotherapy in patients with depressive and anxiety disorders. Adults referred to a psychiatrist completed self-report measures and participated in a diagnostic interview based on DSM-IV criteria. Those with depressive, anxiety or adjustment disorders were included (n = 124). Patients reported the types and dosage of current psychotropic medication as well as number of different psychiatrists and psychologists/counselors they had seen in the past 10 years. Multiple regression analyses were used to examine relationships between attachment anxiety and avoidance and the variables capturing treatment use and attitudes towards treatments. Attachment anxiety was positively associated with the number of current psychiatric medications and with both the number of psychiatrists and the number of psychologists/counselors seen. Attachment avoidance was negatively associated with the number of current psychotropic medications and beliefs about the efficacy of psychotherapy. The findings suggest that patients' attachment characteristics play a role in their views and choices regarding treatments. Developing treatments sensitive to the needs of insecurely attached individuals may lead to improved treatment outcomes.

[Relationship Pattern of Mothers with Functional Constipated Infants]

Relationship Pattern of Mothers with Functional Constipated Infants The present article investigates whether or not mothers of infants with functional constipation have a specific relationship pattern. This question is addressed by analyzing the data collected at the day care clinic for infant regulation disorders with appropriate methods like the questionnaire for the assessment of adjustment of mothers with children in infancy (EMKK, Engfer u. Codreanu, 1984) described here. The evaluation of data was performed in two ways: first with regard to the clinical study group of mothers with infants (age range from one to five years) suffering from functional constipation, and then compared to a clinical control group of mothers with infants who are coping with regulation disorders (by definition per Papouŝek, Schieche, Wurmser, 2010). With this comparison differences between the two groups are made visible and clinical interventions can be deduced accordingly. If the groups do not differ in their pattern described by the EMKK, the possible interventions can be adopted from the well-studied area of regulation disorders. The focus on analyzing the data of mothers with functional constipated infants serves as an important starting point for providing the best possible alignment of clinical intervention.

[The influence of the attachment dimensions "anxiety" and "avoidance" on psychosomatic complaints]

OBJECTIVES

In contemporary literature, insecure attachment styles have been identified as nonspecific vulnerability factors for psychosomatic disorders. Further, they are also associated with aggravation of the assessment of complaints (Maunder and Hunter 2001; Strauß and Schwark 2007). The present study investigates the extent to which attachment-related anxiety and avoidance are related with the intensity of psychosomatic complaints.

METHODS

Prior to an initial diagnostic interview, 166 patients from a psychosomatic outpatient department were tested with the questionnaires ECR-RD and SCL-90-R. A model of two latent attachment dimensions, fear (BANG) and avoidance (BVER) in close relationships, underlying the scales of the ECR-RD, was used (Ehrenthal et al. 2009). The GSI was chosen as a good validated, global value from SCL-90-R (Franke 2002) for measuring the psychosomatic pressure caused by complaints.

RESULT

As expected, our results demonstrate strong positive correlations between BANG and GSI, whereas BVER and GSI showed a moderate, positive connection. Thus, both attachment dimensions were able to predict a significant ratio of GSI in a multiple regression analysis.

CONCLUSION

This study confirmed a systematic relationship between insecure attachment representations and psychosomatic complaints, although some limitations must be noted due to the heterogeneous answer patterns of the BVER-scale. However, in our view, the ECR-RD measure should be used in other clinical studies, the goal being to become a diagnostic standard screening tool for assessing the influence of patients' attachment style on their presentation of psychosomatic complaints.

Attachment styles and outcome of psychoanalytic psychotherapy for children and adolescents

BACKGROUND

Until now few studies have proven that an attachment style can be changed in the course of psychotherapy and that the attachment style has an impact on the therapy outcome. In particular, there is a lack of studies about these relationships in long-term psychoanalytic psychotherapy with children and adolescents.

SAMPLING AND METHODS

Seventy-one children with mental disorders receiving long-term outpatient psychodynamic psychotherapy were assessed 4 times using the Heidelberg Attachment Style Rating for Children and Adolescents. The measurements were conducted at the beginning of treatment, at the 25th treatment session, at the end of treatment and 1 year after the completion of treatment.

RESULTS

The results showed a significant change in attachment style during treatment. The proportion of children and adolescents with a secure attachment style increased from 23% to 63%. There was no significant difference in the attachment style between patients with good and poor treatment outcome, but a significant relationship between secure attachment and the number of treatment sessions could be demonstrated.

CONCLUSIONS

A reorientation towards a secure main attachment style over the course of psychotherapy is possible. However, attachment style seems to be not a moderator but a mediator for the outcome of psychoanalytic psychotherapy in children and adolescents.

Therapist effects in the therapeutic alliance-outcome relationship: a restricted-maximum likelihood meta-analysis

OBJECTIVE

Although the relationship between the therapeutic alliance and outcome has been supported consistently across several studies and meta-analyses, there is less known about how the patient and therapist contribute to this relationship. The purpose of this present meta-analysis was to (1) test for therapist effects in the alliance-outcome correlation and (2) extend the findings of previous research by examining several potential confounds/covariates of this relationship.

METHOD

A random effects analysis examined several moderators of the alliance-outcome correlation. These included (a) patient-therapist ratio (patient N divided by therapist N), (b) alliance and outcome rater (patient, therapist, and observer), (c) alliance measure, (d) research design and (e) DSM IV Axis II diagnosis.

RESULTS

The patient-therapist ratio (PTR) was a significant moderator of the alliance-outcome correlation. Controlling for several potential confounds in a multi-predictor meta-regression, including rater of alliance, research design, percentage of patient Axis II diagnoses, rater of outcome and alliance measure, PTR remained a significant moderator of the alliance-outcome correlation.

CONCLUSION

Corroborating previous research, therapist variability in the alliance appears to be more important than patient variability for improved patient outcomes. This relationship remains significant even when simultaneously controlling for several potential covariates of this relationship.