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Steel, C., Macdonald, J., & Schroder, T. (2017). A systematic review of the effect of therapists’ internalized models of relationships on the quality of the therapeutic relationship. Journal of Clinical Psychology. Advance online publication.

Therapists likely respond differently to different clients, due to their own personal characteristics and unconscious processes.Relational theory suggests that the therapist’s particular qualities combine with the client’s particular qualities to form a unique interpersonal context. The interpersonal context of therapy may be influenced by client and therapist internalized patterns of relating which are likely formed in early childhood. The attachment theory concept of internal working models is one way to understand therapists’ internalized patterns of relating. Internal working models are like templates that help one to predict how relationships with others work. Internal working models of self indicate the quality of one’s self-concept. In this systematic review, Steel and colleagues examined a total 22 studies and asked: do therapists’ secure attachments and positive internal working models affect the quality of the therapeutic relationship with clients? There were too few studies on the specific concepts to conduct meta analyses to aggregate effect sizes, so the authors simply reviewed the literature. Eighteen of 22 studies showed an association between therapist internalized relational models/attachment security/self concept and the therapeutic relationship. Three of four studies that looked specifically at therapist attachment found that therapist secure attachment was associated with a more positive therapeutic relationship. Among these studies, all forms of therapist attachment insecurity were associated with poorer relationship quality with clients and with lower levels of therapist empathy. Four of five studies that examined the effects of internal working models of self indicated that greater therapist negative self-concepts (i.e., self-criticism, neglecting of self, hostility towards self) was associated with a poorer therapeutic alliance with clients. 

Practice Implications

Therapist effects (i.e., the differences between therapists) are emerging as important predictors of client outcomes. It is possible that therapists’ views of others and of self (i.e., internal working models) contribute to these differences. However, there are relatively few studies that examine psychotherapists’ views of self and of others and the impact on therapy. The research that does exist suggests important issues for therapists to consider. Therapists that are insecurely attached (i.e., are dismissive of the importance of relationships or are overly preoccupied with relationships) may have problems in developing positive therapeutic relationships and may be perceived as less empathic by clients. Therapists who have an overly negative view of their self (i.e., self critical, self neglecting) may struggle with developing a therapeutic alliance with clients. The findings suggest that clinicians need to be aware of their internalized relational models. The process of recognizing, reflecting on, and extricating from maladaptive interpersonal patterns and self-concepts may require supervision and/or personal therapy.

Author email: katiecatherinesteel@gmail.com

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Some authors argue that client factors account for 30% of variance in outcomes. That represents a greater association to psychotherapy outcome than therapist effects and therapeutic techniques combined. In this part of the Handbook chapter on client factors, Bohart and Wade discuss client attachment. Bowlby found that attachment relationships were important and were different from other relationships. Attachment figures confer a sense of security and safety to infants that allow children to explore their environment and experience the self. Attachment patterns that develop in childhood tend to be stable throughout the lifespan, but attachment style can change with positive (i.e., psychotherapy, romantic relationships) and negative (i.e., traumatic events) experiences. Attachment security is associated with adaptive affect regulation, positive view of self and others, and reflective functioning that is related to mentalizing. Attachment anxiety is associated with maladaptive up-regulation of emotions, positive view of others but negative view of self, and reduced reflective functioning likely due to preoccupation with relationships and emotion dysregulation. Attachment avoidance is associated with maladaptive down-regulation of emotions, negative view of others and positive view of self (or negative view of others and negative view of self in the case of fearful avoidant attachment), and limited reflective functioning due to dismissing of emotions and relationships. There are also disorganized attachment states related to traumatic events. Those with attachment avoidance tend to be distrustful and less likely to seek psychotherapy. A meta-analysis by Levy and colleagues (2011) of 19 studies including 1467 clients found that attachment security was associated with good psychotherapy outcomes and attachment anxiety was negatively associated with good outcomes. No relationship was found for attachment avoidance and outcomes. Diener and Monroe (2011) conducted a separate meta analysis on attachment and therapeutic alliance which included 17 studies with 886 clients. They found that clients with secure attachments had better alliances with their therapist and those with insecure attachments (anxious or avoidant) had weaker alliances.

Practice Implications

The research is clear that client attachment style influences how clients enter therapy, engage with the therapist, and experience outcomes. Attachment style likely affects specific therapy behaviors like self-disclosure and amount of exploration. In his book Attachment and Psychotherapy, David Wallin (2007) translates attachment theory into a framework for adult psychotherapy by tailoring interventions to specific attachment styles. For example, clients with greater attachment anxiety may do better in psychotherapy when the therapist: helps with down regulation of client emotional experiences, behaves in a way that does not evoke client fears of abandonment or loss, and helps clients improve reflective functioning by encouraging a thoughtful appraisal of their behaviors. On the other hand clients with greater attachment avoidance may require a therapist who: slowly introduces the client to greater attention to emotional experiences, does not demand too much from the client in terms of closeness in therapy at the outset, and encourages reflective functioning by helping the client understand the association between defensive avoidance of affect and relationship problems.