Therapeutic alliance, attachment theory, and retention in therapy

Therapeutic Alliance, Attachment Theory and Retention in Therapy

Numerous studies have established that, "...therapeutic alliance is an essential component of successful therapy. All forms of individual psychotherapy have demonstrated a connection between outcome and therapeutic alliance "(Delaney, 2006). It is important to note that the significance of the therapeutic alliance goes beyond the parameters any one theory and is considered a "pantheoretical" factor of treatment. (Delaney, 2006) While the general concept and praxis of therapeutic alliance is associated with outcome, it is also aligned with the issue of retention.

This study will attempt to provide an overview of the relationship between therapeutic alliance and retention with reference to the underlying influence of attachment theory. The subject of therapeutic alliance has been in recent years the subject of numerous papers and studies and it is often seen as an essential element of the therapeutic process.

A central aim of this study is, through the analysis of the interrelationship between alliance, retention and attachment theory, to provide the groundwork to determine whether one can detect if the client experiencing the therapeutic alliance in a positive way. Related to this is the need to ascertain the effectiveness of therapy and alliance from both the client or patient's point-of-view and from the perspective of the therapist.

Another issue at stake in this study is to ascertain the most appropriate stage for determining the effective measurement of the status of the alliance. These in turn leads to important practical issues, such as the type of action that she be taken if the therapeutic alliance is not beneficial and whether the patient should be referred to another therapist or work through the alliance difficulties.

Brief background to the understanding of therapeutic alliance brief overview of the history and significance of therapeutic alliance is necessary as a prolegomena to the understanding of the links or the variables that intersect between therapeutic alliance and retention.

In a contemporary sense, therapeutic alliance is an essential part of psychotherapy can be traced to Bordin's (1979) conceptualization of the alliance. This is a clearly measurable and definable concept. Bordin's definition of therapeutic alliance consists of three interconnected components. These are:

The body of trust between therapist and client or patient.

The agreement on the goals of the theory.

Tasks or the agreement on the specific activates that facilitate the development of therapy towards various intervention goals. (FAW et al. 2005)

Furthermore, the therapeutic alliance is considered as "...the most important determinant in treatment continuance and success... As well as the most frequently identified factor contributing to the outcome of therapy" (Delaney R.O. 2006).

The imperative nature of therapeutic alliance and the collaborative aspect of therapy in psychoanalytic theory can be related back to the work of Freud. This refers to the impact in Freud's theory of the concept of transference, where, "....the client displacing repressed wishes, fantasies, and aspects of past relationships from childhood onto the therapist" (Delaney R.O. 2006). The question of retention and the reason for a patient choosing to endure and remain in the process of therapy was raised by Freud. (Freud, 1912) the answer that Freud gave to this his question reflects on the issues at stake in this paper.

He concluded that the client was able to view the therapeutic relationship as positive aspects of previous relationships and that the client could bond with, or have an alliance with, the therapist to work together to fight against the client's negative past experiences. Freud then viewed this as an aspect of the client's positive ego that was capable of forming a real, true bond with the therapist's rational ego. (Delaney R.O. 2006).

The above quotation points to a number of issues that will be explored in this paper. The first is that retention is directly connected to the perceptions of the therapeutic alliance. The patient or client's perception of the bond that is formed - particularly within the first few sessions - is a determining factor in the period of retention. Secondly, the process of therapeutic alliance works both ways in terms of perception and is concerned as well with the way that the therapist perceives the worth or value of the therapeutic alliance.

In 1934, Sterba defined alliance as the relationship between the reasonable aspects of both the therapist and the client. (Sterba, 1934) Therefore, in order to enable positive outcomes and retention, the client's ego "...needed to be strengthened in its interactions with the therapist" (Delaney, 2006). This process was facilitated by an intense form of understanding and cooperation between therapist and client. The concept of alliance was therefore seen as an indispensable process, whereby the client would accept or acquiesce to the therapist's view and insight into the particular problem, which in turn would increase the likelihood of positive outcomes to the therapy.

The view of therapeutic alliance was taken further by therapists such as Zetzel, Rogers and Greenson in the 1950s and 1960s. These therapists advanced beyond the theory of transference towards an understanding of the therapeutic alliance as a conscious process, which leads to the development of a situation of trust and cooperation between the client and the therapist.

For example, Zetzel (1956) redefined the therapeutic alliance as describing "...the authentic object relationship which promoted the client's ability to withstand analysis" (Delaney, 2006). This view stresses the way that the therapeutic alliance also alters or potentially changes the perceptions and emotional and cognitive stance of the client or patent. Zetzel believed that,."..it was the ability to foster and maintain this alliance with even the most disturbed clients that would allow for a successful analysis of the transference and the success of the treatment "(Delaney, 2006).

This view was developed by other theorists such as Rogers (1957), in which the therapeutic relationship between the patient and the therapist was placed at the centre of the therapy. In this regard, a central aim for the therapist was to establish a firm, stable and consistent relationship or alliance with the patient or client. For this to occur there were certain preconditions that need to exist. These included, among others, that there had to be psychological context between the therapist and client; the therapist should invest in the relationship; there should also be unequivocal acceptance of one another; empathy and, importantly, that the client should be aware of and understand the aims and interaction with the therapist.

These theories were to lead to numerous clinical trials in the 1950 and 60s, which tended to establish the view that empathic client - therapist alliances resulted in better results and outcomes. (Horvath, 2001). A study by Horvath, (2001) reveals a cardinal issue. This was that the behavior and actions of the therapist were not as important as the way that the client or patient perceived these actions or behaviors. (Horvath, 2001)

In other words, the way that the client reacted to the intention and the degree of empathy from the therapist was deemed the most significant aspect in the therapeutic process in terms of positive outcomes and retention measurement. This is supported by theorists like Greenson who noted that that positive collaboration between client and therapist was one of the essential components for therapeutic success. (Greenson, 1967)

The concept of therapeutic alliance was further developed in the late 1970s by Luborsky (1976). He redefined the contemporary understanding of therapeutic alliance. In this definition, the way that the therapist made the client feel safe and accepted was emphasized. Secondly, the client is encouraged to cooperate and even collaborate with the therapist in the process of therapy. (Luborsky, 1976) This type of alliance would then lead to a form of shared commitment from both client and therapist, which would have the best chance of positive therapeutic outcomes.

Bordin was to take this redefinition of therapeutic alliance further and establish certain criteria that were measurable and clear. In Bordin's view, the alliance between the client and the therapist was a conscious and collaborative relationship, which was not concerned with transference. (Bordin, 1979)

In essence, this view stresses that in the first instance there should be an agreement between the client and the therapist as to the aims and intentions of the therapy; as well as an agreement on certain specific tasks and their aims and purposes within the ambit of the therapy. (Bordin 1979) Finally, the tasks, aims and the actions in the therapeutic alliance should be consistent with the milieu and the lifestyle of the client or patient.

Agreement on goals occurs when the clients and the therapist agree about the targets of change while in therapy. The clients must also perceive that the therapist is truly invested in helping them to achieve their goals, aided by a mutual fondness, attachment and trust (Delaney R.O. 2006).

All these theoretical aspects tended to elevate the importance of the therapeutic alliance in psychotherapy. The therapeutic alliance was seen in many instances as being in itself therapeutic. (Rogers 1957). In the 1900s, therapeutic alliance was seen by many as being a prerequisite for effective therapy and essential for positive outcome as well as retention.

An important point emphasized by many theorists was that it was essential for the therapeutic alliance to be flexible in order to accommodate the patient or client's perceptions. Another cardinal aspect that was emphasizes by clinicians and theorists was that the therapeutic alliance had the ability to create and promote change in the client. In other words, the therapeutic alliance should be varied enough to deal with the various levels of functioning of the patient. At the same time, it should be flexible enough to accommodate the interventions of the therapist. (Gaston, 1990)

These theories were reinforced by further studies and statistical measurement. Researchers found that there was a significant statistical correlation between therapeutic alliance and positive outcomes in therapy. In this regard, a study by Horvath and Symonds, (1991) established that alliance accounted for almost fifty percent of the variance in the measurable outcome of therapy. In the words, it could be statistically shown that therapeutic alliance had a profound impact on the issue of outcomes. Furthermore, this finding was shown to be consistent across therapy involving different kinds of theoretical input.

IN 1974, Horwitz conducted a study of 42 patients. While half of these patients were treated with individual psychotherapy and the other half with individual psychoanalysis, the study found that, "....there were no differences in the outcomes of the two methods but that there was a marked difference due to therapeutic alliance" (Delaney R.O. 2006).

These results are therefore generally consistent in different therapeutic categories and forms of therapy. For example, therapeutic alliance has been shown to have a significant impact in drug abuse therapy, as well as in the cognitive-behavioral treatment of children with behavioral problems. (Delaney, 2006)

It has also been found to be consistent in alcoholism therapy and martial therapy. The perceived importance of therapeutic alliance is evident in the following assessment. "The alliance itself appears to have therapeutic properties due to the relationship between client and therapist, involving collaboration and acceptance, providing a mode for treatment that is beneficial in its own right" (Delaney R.O. 2006).

The literature also notes the importance of the agreement about tasks between the client and the therapist in the overall therapeutic alliance. In this regard, a study by Orne and Wender (1968) states that, "...the transactions which take place in psychotherapy... can run their normal course only if the participants are familiar with certain ground rules, including the purpose of the enterprise and the roles to be played by the participants" (Orne and Wender,1968, p. 1202)

Another cardinal issue in the literature relating to the evaluation of the therapeutic alliance in terms of positive outcomes and retention, is that the main body of research on alliance has to date been mostly based on cases with individual clients. (Horvath & Bedi, 2002) the understanding of therapeutic alliance from a system theoretical point-of-view was only researched in the 1990s. This refers particularly to the understanding of the way that that therapeutic alliance affects marriage and family therapy and the importance of the mutual interaction and alliance in groups in the therapy session.

3. The value of therapeutic alliance and its relationship to retention

The term therapeutic alliance has many variations in the literature. The relationship between client and therapist has been termed working alliance, therapeutic bond, ego alliance, and helping alliance. (Delaney, 2006) One definition of therapeutic alliance is "...maintaining open and clear communication that conveys understanding, support, and respect to the client and focuses more on the personal closeness" (Horvath, 2001).

The question of the importance and the significance of the therapeutic alliance have been addressed to a certain extent in the studies cited in the previous section; however the contemporary approach to the issue of therapeutic alliance is also seen to be a matter of perspective. This relates to the important question of the assessment of the quality and the value of a therapeutic alliance by both client and therapist - which is in turn an aspect that directly affects the issue of retention.

The value of therapeutic alliance and its connection to positive clinical outcomes has been noted in various studies. Fenton et al. In an article entitled, Perspective Is Everything: The Predictive Validity of Six Working Alliance Instruments, state the following.

Clinical trials employing cognitive, interpersonal, behavioral, and psychodynamic therapies have demonstrated the robust nature of this finding. A strong alliance has been associated with an improved outcome in the treatment of a variety of psychological problems, including depression, personality disorders, alcohol dependence, and cocaine dependence.

Fenton et al.)

Interestingly, the above study also notes that the more empirical methods of measurement of the relationship between the client and therapist seem to indicate, in some cases, that therapeutic alliance does not dramatically foster positive therapeutic outcomes. However, this result is ascribed in the study to the types of measure techniques used. The study also points out that;

researchers should be aware that when outcome measures are highly objective, therapist- and client-rated measures of the alliance may not be strong predictors of outcome, in contrast to studies that rely on more subjective measures or in which process-outcome relationships are evaluated using only homogeneous perspectives (e.g., patient-patient, therapist-therapist).

Fenton et al.)

This aspect will be embroidered on the later sections of this paper.

What is very clear from a wide range of studies on this issue is that the early development of a positive therapeutic alliance is known to aid in positive outcomes in therapy. In research by Horvath and Symonds (1991) involving more than twenty clinical studies, the findings are enlightening with regard to the impact of therapeutic alliance. The study found that the therapeutic alliance is a significant predictor of individual therapy outcome (Horvath, 2001). Importantly, it was also determined that, "Due to empirical evidence, it has been recommended that the optimal time to document the relation between outcome and alliance is during the early phase of the therapeutic process" (Delaney, 2006).

This optimal period is usually determined as the period between the second and fourth therapy sessions. This question of the most relevant time for measurement of alliance also impacts on the issue of retention and other questions that will be further explored in this paper.

Figure 1: Outline of the relationship between client and therapist in terms of the position and importance therapeutic alliance.

Source: (http://www.pep-web.org/document.php?id=jaa.003.0021.fig004.jpg)

Other studies show that the development of a strong alliance between patient and therapist by the end of the third therapy session is indicative of outcomes that are more positive as well as in follow-up procedures. Johnson and Talitman (1997) also found in clinical tests that it is generally more effective in terms of results to develop a positive therapeutic alliance as early as possible early in the therapeutic process. Conversely, Brown and O'Leary, (2000), concluded that in most cases the lack of a positive therapeutic alliance resulted in a lack of therapeutic progress and poor outcomes and retention. (Brown and O'Leary, 2000)

Similarly, other studies have found that there is a strong positive correlation between positive and early development of therapeutic alliance and positive outcomes.

Horvath and Symonds, (1991), found in a study comparing the time period over which a positive therapeutic alliance was developed, that predictive and positive outcomes were strongly linked to strong bonds or alliances that were established in the initial stages of the therapy. This also applied to the issue of retention. The earlier period of alliance building was seen as a "window of opportunity" which allowed for the possible development of good therapeutic outcomes. This window tends to close as the theory sessions progress.

In this view, it is therefore essential to establish good alliance patterns early on in the therapy. Even more importantly, the above study indicates that the potential of alliance in relation to positive outcomes is largely dependent on the perception that the client or patient has of the alliance.

A it is most important to assess the client's perception of the alliance because the client's assessment of alliance is more predictive of treatment" (Delaney, 2006).

In other words, this finding points to the fact that an assessment of the retention value of a therapeutic alliance can be best determined in the early stages of the therapy. In a meta-analysis of 79 studies involving individual therapeutic treatment, it was found that, "....alliance is consistently related to outcome and that, if a strong alliance is established, the client will experience that relationship as therapeutic. Throughout the meta-analysis, the clients viewed of the alliance remained stable..." This also refers to the finding that the therapy is viewed by patients as being positive if it was perceived as positive at the outset.

Other research even goes as far as to assert that therapeutic alliance is in fact more important than the types of treatment used in theory. (Safran and Muran, 1996) Therapeutic alliance has become so important to therapy that it has even been referred to as the"...quintessential integrative variable" (Delaney, 2006). Research that is more recent has added to the consensus about the importance of therapeutic alliance in clinical praxis. For example, Horvath and Bedi (2002) found that constructive change in the therapeutic situation could be the result of a strong alliance or bond between the client and the therapist.

As noted above, these findings also tend to apply to specific types of therapy. In a study of drug addiction entitled, the role of the therapeutic alliance in the treatment of substance misuse: a critical review of the literature by Meierwet et al. (2005), it was found that the early development of a positive therapeutic alliance was an important aspect of both engagement and retention in patents with drug addiction problems. However, the same study also found that early alliance was inconsistent as a means of predicting long-term or post-treatment outcomes. (Faw et al.) study that investigates the importance of alliance in term of outcomes as well to the issue of retention is Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review by Martin et al. (2000). Martin et al. conducted a metal-analysis of seventy - nine studies on alliance that have been conducted over the period of twenty years. An important aspect of the results of the study was that alliance was shown to have a "moderate" effect on outcomes and, "...This moderate effect was consistent regardless of who rated the alliance (e.g., client therapist, observer), when the alliance was measured (e.g., early or late in treatment), type of outcome measure, or type of treatment" (Faw et al.).

However, in a more inclusive and extensive analyses and assessments of the various studies of alliance it has been found that "...over half of the positive outcomes attained in psychotherapy are linked to quality of the alliance" (Faw et al.).

These findings would tend to suggest that studies vary in the extent to which they ascribe value to therapeutic alliance in terms of both outcomes and retention. However, the previous reference to methodologies and measurement techniques should be borne in mind when evaluating these findings.

Another factor that also should be taken into account when evaluating the relevance of therapeutic alliance in outcome and retention is that there are a number of variables that have to be considered.

For example, there has been relatively little research on the impact of therapeutic alliance in terms of the treatment of children and adolescents. "Research on therapeutic alliance with children and adolescents lags far behind research with adults. To date, three published studies have focused on instrumentation in measuring therapeutic alliance in youthful samples" (Faw et al.).

This also refers to the aspect of retention. "In the context of family therapy, a strong therapist alliance with family members other than the adolescent can also affect retention" (Faw et al.).

While the are a number of studies that contradict or at least ameliorate the more positive findings about the relationship between alliance, outcomes and retention, the majority of studies and reports in the literature confirm that there is a strong correlation between these aspects.

3.1. Retention

Specific studies on various types of therapy tend to confirm the positive findings about therapeutic alliance. An interesting study in this regard is, Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, by Barber et al. (2008). In this study, the relationship between therapeutic alliance, retention, and outcomes for 308 cocaine-dependent outpatients participating in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, was explored. The results of the study indicated high levels of alliance in supportive-expressive therapy (SE), cognitive therapy (CT), and individual drug counseling (IDC).

Furthermore, it was found that the levels or the degree of alliance increased between the second and the fifth session in all instances that were studied. This finding therefore supports the assessment noted above that alliance increases as the therapy progresses to produce positive outcomes. The study also suggests that therapeutic alliance did predict various levels of retention access the different types of theory.

In SE and IDC, either higher levels of alliance were associated with increased retention or no relationship between alliance and retention was found, depending on the time alliance was measured. In CT, higher levels of alliance were associated with decreased retention. (Barber J.P. et al. 2008)

This is an important finding in that it suggests that retention values are related to positive therapeutic alliance, despite the different forms of therapy that were employed.

However, the results were not as positive in terms of outcomes in the case of drug addiction.

Another article that examines the relationship between retention and alliance is Predictors of Retention in an Alternative-to-Prison Substance Abuse Treatment Program (2008). This study analyses the predictors of retention among alternative-to-prison substance abuse treatment clients. (Brocato and Wagner 2008)

An important aspect of the study, which relates to the concerns in this paper, is that the roles of motivational factors and the client-therapist relationship are examined. The sample was composed of 141 male felony offenders who were legally mandated to a community-based, long-term residential drug treatment program.

The results of the study indicate the following main findings. In the first instance, retention is strongly correlated and seen to be effectively related to positive motivation and change in therapy. Furthermore and importantly, the variable of retention was related in most instances to motivation and change. (Brocato and Wagner 2008) related study on the effects of alliance on substance abuse theory is,

Early Therapeutic Alliance as a Predictor of Treatment Outcome for Adolescent Cannabis Users in Outpatient Treatment (2006), by Diamond et al. This study examined "...The association of early alliance to treatment attendance and longitudinal outcomes were examined in 356 adolescents participating in a randomized clinical trial targeting cannabis use" (Diamond et al. 2006, p. 26).

An important aspect is that both patient as well as the therapist's perceptions of therapeutic alliance were observed and studied. The summarized results were as follows.

Patient-rated alliance predicted a reduction in cannabis use at three and six months and a reduction in substance- related problem behaviors at six months. Therapist- rated alliance did not predict outcomes. Neither patient nor therapist alliance ratings were associated with attendance. The findings support the important and often overlooked role that alliance can play in treating substance abusing, often delinquent, adolescents. (Diamond et al. 2006, p. 26)

These results lead to certain findings that pertain to the central discourse in this paper.

Individual and meta-analytic studies on the therapeutic alliance with adults have demonstrated that: a) it is established by the third or fourth session; b) early alliance is a better predictor of outcome than later alliance; c) it predicts outcome equally well regardless of theoretical orientations; d) patient, therapist, and observer alliance ratings are all predictive of outcome, with patient's point-of-view being especially predictive; and...there is also evidence that alliance impacts treatment retention. (Diamond et al. 2006, p. 26) number of aspects should be highlighted from the above. The study tends to confirm the previously mentioned finding that early alliance in treatment is predictive of outcomes. Another is the view that therapeutic alliance functions equally well regardless of theoretical orientation. Significantly, the study also finds that both patient and therapist views of the value of the alliance are elements that are significant in terms of the outcomes; and furthermore that these aspects affect the issue of retention.

4. Attachment theory

4.1. A brief overview of attachment theory

Fundamentally, the term "attachment" is used to describe "...the affective bond that develops between an infant and a primary caregiver" (Attachment Theory). According to Bowlby (1980) attachment bonds have four defining features. These refer to;

proximity maintenance (wanting to be physically close to the attachment figure), separation distress, safe haven (retreating to caregiver when sensing danger or feeling anxious), and secure base (exploration of the world knowing that the attachment figure will protect the infant from danger). (Sonkin, 2005)

Sonkin (2005) notes some important aspects that relate to the topic of the present study.

Attachment is not a one-way street. As the caregiver affects the infant, the child also affects the caregiver. Edward Tronick (1989) of the University of Massachusetts, refers to this process as "mutual regulation." Daniel Stern, author of the Interpersonal World of the Infant, (1985) refers to the "attunement" of the caregiver: where the parent is sensitive to the verbal and non-verbal cues of the child, and is able to put himself/herself into the mind of the child. Each of these writers view attachment as central to the capacity of emotion regulation. (Sonkin, 2005)

If one views this theory in terms of the field of psychotherapy then there are a number of cogent aspects that should be noted. In Attachment Theory and Psychotherapy the author makes the following point. "Over the past ten years, a number of individuals have begun to explore how this body of knowledge of attachment theory would apply to clinical practice..." (Sonkin, 2005). Sonkin also emphasizes the view that secure attachment is "... The ability to reflect on one's internal emotional experience, and make sense of it, and at the same time reflect on the mind of another" (Sonkin, 2005). This means that therapeutic alliance and consequently the outcomes in terms of therapy are probelamatized in insecurely attached individuals. These individuals lack the reflective function.

A because their emotional responses are so repressed as in the case of the dismissing attachment status or exacerbated as in the case of the preoccupied attachment status that they are unable to either identify their own internal experience or reflect on that of the other." (Sonkin, 2005).

Therefore, the therapist's role on terms of development of a positive therapeutic alliance with the patient or client must take into account the attachment status of the individual. For example, in the case where the patient or client exhibits preoccupied attachment with extreme anxiety, the therapist attempts to break through the negative cycle in the narrative with the client and to create a relationship that is more balanced. (Sonkin, 2005).

In essence, the permutations of attachment theory are fundamentally based on the view expressed by Bowlby (1969) and others that intimate attachments are the nexus of an individual's personal life. In this sense, the theorist becomes an attachment figure, in terms of this theoretical stance. This has obvious implications for the question of alliance and retention.

Attachment theory therefore sees analysis and therapy as analogous to the way that the child forms attachments in early life. From this perspective, the four tasks of attachment as posited by Bowlby have reference. These refer to proximity maintenance; separation distress; safe haven and secure base. (Sonkin, 2005)

As Sonkin states, "Like the process of developing attachment that occurs in the child-parent relationship, the developing of the therapeutic relationship will follow a similar process: preattachment, attachment in the making, clear-cut attachment and goal corrected partnership..." (Sonkin, 2005). This theoretical perspective therefore coincides with the formation of positive alliances in the therapeutic or clinical situation.

Furthermore, this theoretical trajectory also brings to bear the problem of facilitating the process of alliance creation in terms of the issues surrounding attachment. Issues such as non-verbal communication and contingent communication between the client and therapist have to be considered. Non-verbal forms of communicating are considered extremely important in the therapeutic situation. This also refers to the importance of "now moments." These are to periods of intense interaction between the client and the therapist which are "...rich in potential for change and growth in the client, but also in the therapist and the relationship as well" (Sonkin, 2005). This often leads to a sense of connection, which serves to increase the bond of alliance. This is seen in many studies as an essential part of the creation of a successful therapeutic alliance as well as retention.

At this point, it is possibly instructive to reiterate a central finding from the literature discussed above; that the therapeutic alliance should be understood for the perspective of the therapist as well as the client. The therapist has to "attune " him or herself with the needs and the subtle non-verbal signs that the client projects. This is especially important in ascertaining the success or otherwise of the therapeutic alliance. Sonkin (2005) stresses the importance as well of the way that the patient of client "picks up" or detects the state of mind and the more subtle emotional emanations from the therapist."...changes in the therapist's state-of-mind will be picked up by the client and will either exacerbate or reduce their anxiety. This close attention to the process of contingency is critical to the development of the therapeutic relationship" (Sonkin, 2005). Therefore, the interaction and mutual apperception between therapist and client is a vital element in the development of therapeutic alliance, as ell as in the positive outcome of therapy. (Sonkin, 2005)

Interaction, alliance and retention

The interface between attachment theory, therapeutic alliance and retention form a complex web of interaction and analysis.

An enlightening study that provides some insight into this process is, Effective treatment relationships for persons with serious psychiatric disorders: the importance of attachment states of mind by Tyrrrel et al. (1999).

This study substantiates some of the general findings that have been mentioned previously on the way that interpersonal attachment styles have an affect on client outcomes. The study by Tyrrel et al. explores the way that individuals within therapy perceive and organizes information internally with regard to the therapeutic alliance. This has relevance to the issue of attachment theory and the way that this theory interfaces with issues such as therapy outcomes and retention.

The study posits two different attachment states of mind; namely, deactivating and hyperactivating. (Tyrrell et al., 1999) in brief, the client who exhibits a deactivating state of mind refers to an individual who attempts to deflect or avoid attachment issues and relationship themes. They are characterized by the avoidance of interpersonal relations or connections with others. (Tyrrell et al., 1999)

On the other hand, the hyperactivating attachment states of mind refer to an intense preoccupation with attachment and associations. Patients or clients that fall in the category would therefore be more open to expression of feelings and would be more communicative of stress or other emotions within therapy.

In terms of the management of therapy and the development of positive alliances, the therapist would take cognizance of these different types of patients and attempt to balance their attachment needs and structure to the therapeutic strategy that would be employed. This can be seen in a summary of the study by Tyrrell et al. The authors, hypothesized that case managers (n=21) whose attachment states of mind differ from those of their clients (n=54) would balance their clients' usual strategies and thereby help them better manage their emotional distress and maintain symptomatic and functional stability. They assumed that dissimilar matches would challenge clients' characteristic ways of processing emotion in relationships, thus facilitating the learning of new ways to regulate distress and manage relationships. Results supported these hypotheses. (Tyrrell et al., 1999. p.725)

In other words, the study found that those clients who exhibited a more deactivating state of mind had better outcomes and exhibited a more positive therapeutic alliance measurement when their case manager was less deactivating. Conversely, those therapists or case managers who more deactivating produced better results with less deactivated clients. (Tyrrell et al., 1999)

An article that sheds further light on the clients perception of therapeutic attachment is Participants' Perceptions of Dimensions of the Therapeutic Alliance Over the Course of Therapy by Bachelor and Salame (2000). In this study, the course of the different dimensions of the therapeutic alliance was examined.

The comments in this study echo others in this field. The authors note that, "The therapeutic alliance of client and therapist has been the focus of considerable research attention over the past 15 to 20 years" (Bachelor and Salame, 2000). They also note that intensive interest has been stimulated by, among others, the theories and writings of Bordin. However, besides these points, the study highlights a number of important aspects pertaining to the resent research; for example, stability or variability of the alliance has important clinical as well as empirical implications, including whether increased focus on the relationship is warranted at specific time points in therapy and whether commonly used one-time assessments can be assumed to represent the quality of the alliance throughout therapy." (Bachelor and Salame, 2000)

This study focuses on an area that is rather neglected in the literature; namely, the way in which therapeutic alliance can be affected by various factors over time. This is also a factor in determining retention aspects. It also relates to the issue or question of whether the therapist should continue the therapy or not.