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Waldinger, R.J. & Schulz, M.S. (2016). The long reach of nurturing family environments: Links with midlife emotion-regulatory styles and late-life security in intimate relationships. Psychological Science. DOI: 10.1177/0956797616661556.

Although, not a psychotherapy study, this research has important implications for psychological treatment of adults, including older adults. This research, drawn from the original Grant study, is extraordinary because the sample is from a 78-year long study of 81 men. The original cohort of over 200 men were first assessed as adolescents and young adults between 1939 and 1942. At that time, the original authors conducted intensive interviews of the adolescents` family experiences and current life situations. These men were re-interviewed in mid-life in the 1960s (aged between 45 and 50 years), which included interviews and assessments of challenges in relationships, work functioning, and physical health. Waldinger and Schulz recently re-interviewed these men and their current partner in late-life (aged between 75 and 85 years), with interviews focusing on their current partner relationship. Raters reviewed audio recordings and notes from all the interviews and coded for: (a) quality of family environment in childhood (distant, hostile vs cohesive, warm) - taken from the first interview; (b) style of regulating emotions (suppressive, maladaptive vs engaged, adaptive) – taken from the midlife interview; and (c) security of attachment with their current partner (secure, comforting vs insecure, anxious) – taken from the late-life interview. The authors found that more nurturing early family environments were significantly linked with late-life attachment security with a partner (r = .23, 95% CI = .01, .45), and early family environment was significantly related to midlife adaptive emotion regulation strategies (r = .29, 95% CI = .06, .50). Also, adaptive emotion regulation strategies in midlife were significantly correlated with greater late-life attachment security (r = .23, 95% CI = .05, .51). These are medium-sized correlations, but they are remarkable because they represent associations between variables that were assessed decades apart. Through a statistical mediation analysis, the authors also reported that adaptiveness of emotion-regulation strategies partially explained why positive childhood family environments may lead to late-life attachment security (accounting for 6% of the variance).

Practice Implications

This compelling study adds to the argument that early family environment shapes the way adults regulate their emotions, which in turn affects how they experience relationships in old age. More securely attached adults were better able to meet two challenges associated with aging: accepting vulnerability in depending on a partner, and accepting the responsibility of being depended upon by that partner. The early family environment indeed has a long reach. Psychotherapy directed at reducing the effects of childhood adversity takes on a heightened meaning in the context of these findings. Treatment for adults who struggle with the consequences of non-nurturing early environments should include improving emotion regulation strategies.

Mallinckrodt, B. & Jeong, J. (2015). Meta-analysis of client attachment to therapist: Associations with working alliance and pretherapy attachment. Psychotherapy, 52, 134-139.

Attachment theory has become one of the most important conceptualizations of affect regulation and interpersonal relationships. John Bowlby and others suggested that attachment behaviour is hard wired so that infants can gain proximity to caregivers which is necessary for infant survival. Repeated interactions with caregivers coupled with the variety of caregiver responses (i.e., available, unavailable, or inconsistently available caregiving) lead to children developing internal working models of attachment. These models become the basis for attachment styles in adulthood. Attachment security in adults is associated with the ability to give and receive caring and love, and to adaptively regulate emotions. Attachment avoidance is associated with a tendency to dismiss relationships as important, and to downregulate emotional experiences. Attachment anxiety is associated with a preoccupation with relationships, and to upregulated emotional experiences. In a previous meta analysis, client general attachment security was modestly but significantly associated with higher levels of therapeutic alliance (r = .17). In another meta analysis, higher client general attachment anxiety was associated with poorer client outcomes (r = -.22). In this meta analysis, Mallinckrodt and Jeong assessed whether client attachment to the therapist was associated with client general attachment style and with the therapeutic alliance with the therapist. They included 13 studies representing 1051 client-therapist dyads. Client pre-therapy general attachment avoidance and anxiety were negatively associated with client-therapist attachment security, and the effects were modest but significant (r = -.12, r = -.13). Client-therapist attachment security was positively associated with therapeutic alliance (r = .76) and client-therapist attachment avoidance was negatively associated with therapeutic alliance (r = -.63), and these effects were large.

Practice Implications

Client pre-therapy attachment styles appear to have an impact on their attachment to the therapist. A client pre-therapy attachment style characterized by preoccupation with relationships and an over-emphasis on emotions (i.e., attachment anxiety) will likely lead to similar behaviors and preoccupations in the relationship with the therapist. Mallinckrodt and Jeong suggest that this might be the basis for transference-related phenomenon that therapists and clients experience in the therapeutic relationship. That is, client attachment anxiety and avoidance likely interfere with developing a secure attachment to the therapist. Further, client attachment avoidance with regard to the therapist may result in lower therapeutic alliance, which is key to achieve improved patient outcomes. Despite these challenges, therapists who can facilitate a secure psychotherapy attachment experience for their clients are more likely to see improvements in their clients’ functioning.

Author email: bmallinc@utk.edu

Kossowsky, J., Pfaltz, M., Schneider, S., Taeymans, J., Locher, C., & Gaab, J. (2013). The separation anxiety hypothesis of panic disorder: A meta-analysis. American Journal of Psychiatry, 170, 768-781.

The concept of separation anxiety is intimately tied to attachment theory. Problematic early attachments have negative consequences for adults’ ability to experience and internalize positive relationships which help to develop mental capacities to self sooth, tolerate anxiety, and modulate affect. Separation anxiety is the persistent, excessive, and developmentally inappropriate fear of separation from major attachment figures, like parents. It is one of the most frequently diagnosed childhood anxiety disorders, with a lifetime prevalence of 4.1% to 5.1%. If we knew that separation anxiety is truly related to or causes adult psychopathology, then we would have a better understanding of the development of adult mental disorders and greater reason to quickly and aggressively treat childhood separation anxiety. A meta analysis by Kossowsky and colleagues (2013) begins to address this relationship between separation anxiety and adult disorders. They looked at case-control, prospective, and retrospective studies comparing children with and without separation anxiety disorder with regard to future panic disorder, major depressive disorder, any anxiety disorder, and substance use disorders. The meta analysis included 25 studies of 14, 855 participants. Children with separation anxiety were 3.45 times more likely to develop a panic disorder later on; and 5 studies suggested that children with separation anxiety were 2.19 times more likely to develop future anxiety disorders. Childhood separation anxiety disorder did not increase the risk of future depressive disorders or of future substance use disorders. In a subsequent paper, Milrod and colleagues (2014) reviewed the literature on separation anxiety and psychotherapy outcomes of adult anxiety and mood disorders. Separation anxiety is associated with poor response to treatment of adult anxiety and mood disorders possibly because separation anxiety disrupts the therapeutic relationship. Separation anxiety also predicted non-response to antidepressant medications.

Practice Implications

As Kossowsky and colleagues (2013) indicate, it is possible that children suffering from separation anxiety disorder may be hindered early on in developing skills to help cope with anxiety and strong emotions. Nevertheless, the findings draw our attention to the importance of recognizing and treating separation anxiety as early as possible. A few psychological treatment studies show that disorder-specific parent-child cognitive behavioral therapy is successful in treating separation anxiety in children. For adults, poorer treatment response may reflect difficulty forming and maintaining attachments, including the therapeutic relationship. Milrod and colleagues (2014) suggest that psychotherapies that focus on relationships and separation anxiety by using the dyadic therapist-patient relationship to revisit earlier problematic parent-child relationships may benefit adults with separation anxiety.

Johnson, S.M, Burgess Moser, M., Beckes, L., Smith, A., Dalgliesh… Coan, J.A. (2013). Soothing the threatened brain: Leveraging contact comfort with emotionally focused therapy. PLoS ONE 8(11): e79314. doi:10.1371/journal.pone.0079314.

Attachment theory argues that a felt sense of connection to others provides a secure base and safe haven, thus increasing one’s tolerance for uncertainty and threat. Improved access to and experience of social resources likely help us regulate negative emotions thus reducing our perception of threat. In a previous study, women in a couple were confronted with a threat (the possibility of a shock to the ankle) while their brain was scanned by functional magnetic resonance imaging (fMRI). These women were either holding the hand of their spouse or the hand of a stranger. Women with the highest quality relationships showed lower threat response in the brain especially while they held the hand of their spouse. Holding the hand of a spouse with whom they had a loving relationship reduced the fear response in these women measured directly in the brain by fMRI. In the study by Johnson and colleagues (2013) the authors wanted to see if improving attachment relationship between couples following Emotionally Focused Couples Therapy (EFT) would result reduced responses to threat measured in the brain. Twenty-three couples completed a course of EFT (23 sessions on average) with experienced therapists. EFT is an evidence based couples treatment that conceptualizes couple distress as caused by unmet attachment needs. When feeling emotionally disconnected, partners in a couple may be anxiously blaming or withdrawing, and this pattern exacerbates relationship distress and threat. EFT focuses on repairing attachment bonds between spouses. In this trial, EFT significantly improved couples’ self reported distress from pre to post therapy. The brain of the female member of the couple was scanned in an fMRI before and after EFT. An electrode was fixed to her ankle, and she was threatened with a mild shock. This procedure took place while she was on her own and while she held her partner’s hand. Threat response was measured by activity in the prefrontal cortex and dorsal anterior cingulate cortex, both of which are associated with processing threat cues and negative affect. EFT resulted in a decrease activity in these areas of the brain from pre to post couples treatment, and these results were especially prominent during hand holding with the partner.

Practice Implications

There is emerging evidence that the effects of psychotherapy like EFT for couples, has a direct impact on the brain that correlates with patients’ self report. In addition, EFT appears to increase the attachment bond between couples and this helps them to regulate their emotions and to moderate their reactions to threat. This study by Johnson and colleagues (2013) also supports some fundamental tenets of attachment theory – that increasing attachment security is possible with psychotherapy and doing so improves affect regulation as measured in the brain. This has broad implications because strong social and attachment bonds help us live longer and enjoy better health.

Author email: jcoan@virginia.edu

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.