ATTACHMENT STYLE AND IPT

Dr Jamie Barsky, Clinical Psychologist

IPT-A Course Lead, North West CYP-IAPT

IPT-UK Training Committee Chair

29 November 2019

Credit to Dr Maddie Marczak & Dr Kat Tidswell

PLAN FOR THE DAY

• Very brief introduction to attachment theory

• Attachment style in adulthood

• Therapeutic considerations in IPT

• Case examples

• Adapting practice to meet the attachment needs of your client

Health Warning!

• We all have attachments – talking about attachment often makes

people think about their own relationships. Take care of yourselves

and each other.

• Remember that all parents do the best they can at the time,

sometimes under very difficult circumstances. Even when their

behaviour is less than ideal, most parents act out of good

intentions.

• Attachment is a complex subject. Today will just be a whistle-stop

tour! Extensive literature to refer to.

• Today’s workshop is not about diagnosis or pathology but about

understanding, validation and adaptation.

WHAT IS ATTACHMENT?

ATTACHMENT THEORY’S ORIGINS

• John Bowlby and Mary Ainsworth developed a theory of attachment in the

1960’s.

• Bowlby says “the young child’s hunger for his mother’s presence is as great as

his hunger for food” – quote taken from Levy and Johnson (2019)

ATTACHMENT

• “An attachment may be defined as an affectional tie that one person or animal forms between himself and another specific one - a tie that binds them together in space and endures over time”. (Ainsworth, Bell & Stayton, 1974, p.31)

• A secure base from which to explore:

• When danger/threat is felt: attachment system is activated

• When danger subsides: exploring can continue

• Shouldn’t see attachment behaviours at other times

• Attachment is a theory about protection from danger

• It’s all about...

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STAYING ALIVE!

9

THE FUNCTION OF ATTACHMENT

• Evolutionary advantage to seek proximity to care givers at times

of threat or danger

• The separation anxiety that follows disconnection from one’s

carer is therefore functional and adaptive

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ADOLESCENCE

• Independence increases through exploration - experimental

behaviour, taking risks, pushing boundaries etc.

• Requires the knowledge that they have a secure base - someone

is there for them when they need to come back and feel safe

again.

• Key tasks:

• 1) Identity Formation- who am I and what do I want from my life?

• 2) Renegotiating Relationships - Greater investment in peer

relationships, exploration of sexual relationships, relating to

parents in a different way.

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ADULTHOOD

“Research on adult attachment is guided by the assumption that the same motivational system that gives rise to the close emotional bond between parents and their children is responsible for the bond that develops between adults in emotionally intimate relationships.” 2018 R. Chris Fraley http://labs.psychology.illinois.edu/~rcfraley/attachment.htm

Attachment patterns in adulthood tend to map on to those in childhood, including the distribution of different patterns across the population.

Attachment systems get activated “from the cradle to the grave” in close and intimate relationships such as…..

Concept of “earned secure” attachment indicates the scope for some adults to have overcome early negative attachment experiences by achieving “structural sophistication in their parental representations” – Levy and Johnson (2019)

Importance of ‘Reflective Functioning’ capacity to reduce day to day impact of insecure attachment style

INTERNAL WORKING MODELS

• Attachment patterns/styles focus on the observable behavioral responses

between people

• But Attachment Theory proposes intra-psychic ‘internal working models’ of

our selves and the people around us.

• Similar to underlying schema in cognitive theory, these models represent the

interpersonal world around us and function at a more physical, emotional and

sub-conscious level

IMPLICATIONS OF A SECURE ATTACHMENT

• Emotional regulation

• Identify and label emotions and Regulate and control emotions

• More positive affect (Sroufe, 1985)

• Ability to tolerate stressful situations

• Understanding of others

• Empathy, socialisation and moral development (Rose-Krasnor et al, 1996)

• Greater conflict resolution skills (Cassidy et al, 1996)

• Better outcomes!

• More school ready and better school achievements (Finnegan et al, 1996; Fagot et al, 1996)

• Greater language skills (Van Ljzendoorn et al. 1995)

• Less mental health problems in adult life.

• Positive Internal working model:

• Self: Loveable, worthwhile, capable and important.

• More positive perception of self (Verschuerenm et al, 1996)

• Relationships/Carers: reliable, trustworthy, meet my needs, available and responsive

• World: Safe, predictable 14

DISRUPTIONS TO ATTACHMENT

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Development of Insecure Attachment

⚫ Children develop insecure attachments when over time the care they receive is not sensitive and responsive to their needs.

⚫ There are a number of different types of insecure attachment styles but they fall into three main categories:

Insecure Avoidant (Type A) – ‘Dismissing’ in adulthood

Insecure Ambivalent (Type C) – ‘Preoccupied’ in adulthood

Insecure Disorganised – ‘Fearful’ in adulthood

16

17

Physical or Psychological Need

e.g. need food, winding, nappy change,

sleep, cuddle, closeness, warmth

Displeasure, discomfort,

high arousal

e.g. I’m cold, hungry, tired, wet,

poorly, scared, angry, unsafe

Parent responds

inconsistently – sometimes

sensitively, other times not

Child cannot rely on parent to

meet their needs

Type C - The Ambivalent Strategy

Child feels more anxious

and stressed

When the cycle is repeated the

child learns to maximise their

attachment behaviours in an

attempt to make parent

available to them

TYPE C ATTACHMENT PATTERNS

• Children who have received inconsistent care continue to use

behaviour to communicate and will alternate between displaying

coy behaviour, to disarm their parents, and aggressive

behaviour, to get their attention, in an exaggerated way.

• They will not let their parents resolve the problem

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19

Physical or Psychological Need

e.g. need food, winding, nappy change,

sleep, cuddle, closeness, warmth

Displeasure, discomfort,

high arousal

e.g. I’m cold, hungry, tired, wet,

poorly, scared, angry, unsafe

Parent is agitated or

annoyed by childParent tries to control or deny

the attachment behaviour

Type A - The Avoidant Strategy

Child’s need is not met.

The attachment behaviour achieves the

opposite of proximity and security.

Child feels more anxious

and stressed

When cycle repeated, child

learns that best strategy to

maintain closeness is to inhibit

feelings and please parent

TYPE A ATTACHMENT

• Children who have been predictably punished or ignored and

have learnt to inhibit negative feelings start

o to use language to please the parent rather than express

themselves

o to display positive feelings that they don’t really feel (false

positive affect) ...

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IMPLICATIONS OF INSECURE ATTACHMENT (1)

• Difficulties regulating:

• Stress - Can’t self-soothe when stress increases.

• Emotion - Can’t manage increasing arousal. Difficulties in accessing rational thought in face of overwhelming emotion.

• Impulse - Can’t stop & think.

• Shame - Shame overwhelms sense of self. Difficulties in taking responsibility for behaviour or learning from experience.

• Rage - Unable to manage anger. At times can be aggressive and destructive.

• Poorer longer term outcomes

• At increased risk of mental health difficulties including self harm, risk taking, depression, anxiety, conduct disorder. (Fonagy et al, 1996; Rosenstein & Horowitz, 1996).

• More likely to engage in criminal activity (Egeland et al 1993)

• Less able to cope with transitions (E.g. School, Moss et al, 1996)

• Emotionally younger than their peers. Less mature thinking abilities.

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• Self:

• Can impact on a child’s sense of who they are

• The child may feel ineffective, helpless, deficient and unlovable.

• Tends to blame self for negative experiences encountered.

• Can lead to feelings of self-hatred, self-blame, chronic feelings of ineffectiveness

• ‘I am worthless, un-loveable, not wanted, incapable”

• Others:

• Inappropriate reliance on others through excessive help-seeking and dependency or social isolation and disengagement

• Children may have difficulty eliciting or responding to social support

• “People are unreliable, unresponsive and they don’t meet my needs”

• World:

• View the world as being unsafe/frightening and unpredictable.

IMPLICATIONS OF INSECURE ATTACHMENT (2)

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SUMMARY - ATTACHMENT STRATEGIES

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3 main categories of infant to parent attachment strategies

Cognitive Affective

Type

A

Anxious-Avoidant

5-25%

B

Balanced & Secure

55-65%

C

Anxious-Ambivalent

10-15%

Care-

giving

Predictably insensitive,

often hostile, punitive

and rejecting

Predictably sensitive,

communicates openly

with and shows interest

in the child

Unpredictably sensitive,

often cajole, threaten,

trick or bribe

Infant

Affective displays are

punished. Infant

inhibits/avoids true

feelings and uses false

positive affect to elicit

attention. Predictable.

Infant can integrate

cognition and affect,

real communication of

feelings and desires.

Balanced and Secure.

Infant displays

exaggerated affect and

is preoccupied with

attachment figures.

Alternately threatening

and disarming.

Unpredictable.

ATTACHMENT IN ADULTS

7 MINUTE SUMMARY

• https://www.youtube.com/watch?v=GHHCy1IHTUc

Negative view of self

Negative view of others /

Negative view of selfNegative view of others

Positive view of others /

Positive view of self

Brennan, Clark & Shaver (1998)

HOW IS IT ASSESSED IN ADULTS?

• It can be harder to identify attachment styles in adolescents

and adults because:

• Avoidant clients are less likely to attend

• Defensive strategies have been developed so as to mask

underlying attachment systems More reliant on one source of

info (client’s self report), as opposed to observing behaviour,

teacher’s report, carer reports

• BUT – attachment styles are often still evident when you

know what to look for. AAI tries to monitor and interpret

these

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ADULT ATTACHMENT INTERVIEW

ADULT ATTACHMENT INTERVIEW

IMPACT OF ATTACHMENT ON THERAPYLEVY A ND J O HNS O N ( 2019 )

• Worse outcomes for those high on attachment anxiety – true for IPT, and more pronounced for under 25s (Constatino et al. - 2015) – why?

• Sensitive interpersonal style impacts therapeutic relationship?

• Entrenched interpersonal problems are less amenable to change?

• Dependency needs in therapy at odds with goals of therapy?

• Better outcomes for those with secure attachment

• Avoidant attachment less well correlated to outcome, but some indication of better outcomes for CBT compared to IPT – why?

• Focus on relationships > activation of attachment system > interpersonal avoidance > premature disengagement

BOWLBY’S 6 GOALS OF PSYCHOTHERAPY

1. Establish a secure base from which to explore painful life events in a supportive & caring

environment

2. Explore past and current relationships, including expectations, feelings and behaviours

3. Explore and reflect on the therapeutic relationship, including how it relates to

relationships outside of therapy

4. Link past events and relationships to current one

5. Support clients to feel, think and act in new ways within relationships (to revise how

internal working models are expressed)

6. Work towards the internalisation of the safe base created in the therapy room – so that

the client can draw on this at other times.

ATTACHMENT THEORY AND IPT

• “Perhaps [the therapy] most explicitly based on attachment theory is

interpersonal psychotherapy”

• “Building on the importance of a secure base…,in IPT, the therapist is active,

collaborative and empathic. The therapist tends to present in a warm,

compassionate manner. In being active, the therapist tries to balance not being

too directive or dependence promoting”

Levy and Johnson (2019), p. 183

ATTACHMENT THEORY & IPT

• Attachment theory was one of the key organising frameworks for IPT when it was first developed.

• Ravitz et al (2008) describes the importance of attachment theory for understanding the development of depression and rationale for IPT.

“The link between attachment security, stress regulation and social support provide potential mechanisms by which insecure attachment may contribute to depression”

Insecure attachment

Reduced stress

tolerance

Reduced effective use of network

Increased risk of

depression

ATTACHMENT THEORY & IPT

• Ravitz et al (2008) discusses how two clients with depression and the same focal area, may require quite different

treatment adaptations dependent on their attachment style:

“We can consider tailoring our approach according to attachment patterns and interpersonal problems. For

example, two individuals who both present with the IPT problem area of interpersonal disputes…but differ in their

attachment and circumplex profiles, require different strategies to resolve their problems”

ATTACHMENT, IPT & MENTALIZATION

• Mentalization – the capacity to think about mental states in ourselves and others

• The capacity to mentalize is informed by an infant’s attuned care giving experiences

• Mentalization as a concept has been increasingly cited in IPT literature and schools of thought in recent years

• It now features in the core IPT training curriculum

• Activated alongside the attachment system in an unconscious/implicit process

• Also informs/makes up the conscious representations we hold of mental states

• Relevant to many of the therapeutic conversations we have with clients in IPT

REFLECTIVE FUNCTION

• A concept developed as a coding scheme for clinical interviews, such as the AAI, to measure quantitavely

the client’s capacity to reflect on own and others’ mental state.

• Evidence from trials testing the utility of this measure has been problematic – it’s usefulness undermined

by:

• Capacity for RF fluctuates in a given person and is dependant on nature of relationship at a given time

• Could be a state dependant competency – capacity for RF reduces when emotionally aroused

• RF is multi-dimensional whereas this measure gives a total score

• Seems only to be predictive of Borderline PD (the disorder for which many of these ideas were developed)

where there is an abuse history

Choi-Kain & Gunderson (2008)

REFLECTIVE FUNCTIONING QUESTIONNAIRE

1. __ People’s thoughts are a mystery to me (original item 1)

2. __ I don’t always know why I do what I do (original item 17)

3. __ When I get angry I say things without really knowing why I am saying them (original item 22)

4. __ When I get angry I say things that I later regret (original item 29)

5. __ If I feel insecure I can behave in ways that put others’ backs up (original item 35)

6. __ Sometimes I do things without really knowing why (original item 36)

7. __ I always know what I feel (original item 8)

8. __ Strong feelings often cloud my thinking (original item 27)

https://www.ucl.ac.uk/psychoanalysis/research/reflective-functioning-questionnaire-rfq

• Nevertheless:

• RF and mentalization, although difficult to quantify in a single measure, appear to be very

important concepts for therapists to hold in mind when providing therapy

• Fonagy and Bateman propose that without changes in RF and mentalization, there will be no

changes in functioning as a result of psychological therapy.

• Some indication (Clarkin et al., 2007) that clients with low RF do better in more

psychodynamically orientated treatments, whereas clients with high RF, may respond equally well

to more directive and structured approaches.

REFLECTIVE FUNCTION

APPLYING ATTACHMENT IDEAS WITH ADOLESCENTS & ADULTS

• Experience in an adolescent mental health service and using IPT with adults in

private practice

• DBT and IPT-A are my ‘go to’ models

• Not attachment therapy, but attachment informs my thinking regardless of

treatment modality

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CASE EXAMPLES

• Ismail – 22yrs

• Early life events – Mum ill for one year immediately following his birth, he was ill

from 2 years old onwards, no developmental concerns, a good baby “even when ill”

• Current context – chronic glaucoma, visual impairment, daily migraines, academic

disappointment, moved out of area with family – left friends and dad behind.

• Depression symptoms – motivation, sleep, low mood, worry, hopelessness,

withdrawal

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CASE EXAMPLES

• Ismail

• Clues about attachment style:

• Vague and low key description of emotions

• Limited use of or reference to relationships

• Separation from dad = “I just don’t think about him”

• Description of mum = “she’s perfect”

• No confidents

• Prefers solitary time

• What attachment style might we be thinking applies to Ismail43

CASE EXAMPLES

• How might attachment ideas inform how I work with this client?

• What IPT strategies might be useful with Ismail?

• Focus Area strategies?

• General Strategies?

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CASE EXAMPLES

• My approach:

• Respect preference for interpersonal distance

• Careful with choice of language – fewer relationship type words (“we”, “our”, “together”, “relationship”)

• Start with a pragmatic approach

• Problem solving, behavioural changes, focus on cognition

• Gently move more towards exploration of emotion & emotion literacy work – encourage curiosity and expression of emotion once client feels sufficiently secure

• Look at network and encourage tolerable use of relationships

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LEARNING FROM MISTAKES

• Client who was very avoidant

• Looked away

• Could only write down emotionally salient ideas

• Seemed acutely uncomfortable in therapy

• What went well – early engagement facilitated by light hearted approach, use of humour and creative approaches to facilitate expression

• What didn’t go well – Client presented as withdrawn and closed down in session 5 – I reacted impatiently. Driven by frustration I encouraged the client to address her body language (drawing on ideas from DBT body work). She should sit up, back straight and look forwards. She recoiled and said “I cant do this anymore”. She left the room and never came back.

• Learning – I should have held in mind her avoidant attachment style. I should have sensitively noted her withdrawal and commented on how hard the session seemed for her today. I should have validated how difficult therapy must feel for her at times, and normalised this, making it less personally focussed – “lots of people also struggle to talk in therapy”. I should have thought about and asked, given the early stage of therapy, what I could do to make things feel easier for her today.

AVOIDANT ATTACHMENT STYLES IN THERAPEUTIC WORK

• Avoidant client

• Avoids closeness – appear self-

contained.

• Won’t ask for help/ miscue that

things are OK.

• Task focussed

• Therapist may feel a desire to “break

through the armour” – the ‘Good

Will Hunting’ effect

• Note that the greater the need, the

greater the anxiety, the greater the

avoidance

client

tasktherapist

TYPE A – SUPPORTING ENGAGEMENT

• Don’t just react, explore what’s being communicated to you: -

• What’s changed since the referral

• What are their expectations or concerns about working with you?

• Note that other people in this situation find it helpful…

• Use less direct ways of supporting them e.g. summarising important points in letters, using text messages to indicate your availability…

• Validate the expressed feeling (that they’re ok and want to go it alone) AND the hidden feeling (fear of service involvement)

• Let this inform your formulation – preferred ways of coping – pros and cons of this approach. What is a tolerable change in how the client can use support/express self

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ADAPTING THERAPY STYLE TO MEET ATTACHMENT NEEDS: AVOIDANT

ATTACHMENTRespecting the need for distance

• The challenge: their desire to maintain distance and independence, downplaying difficult emotional states

• Balance to strike: Enable them to maintain preferred sense of control over feelings but don’t just leave them to themselves as this would intensify their avoidant pattern

• Top tips:

• Avoid increasing discomfort in help seeking position as this may activate shame & lead to drop out – “you felt vulnerable when that happened” may not be helpful – try “Lots of people might have struggled with that – what went through your mind as it happened”

• Keep contact relatively formal/business-like - match client’s communication style – less use of relationship words

• Actively structure dialogue – ask questions – explain why answers are ‘relevant’ to allow client to feel ‘co-responsible’. Bring reason/logic to discussions of affect – “it makes sense that you reacted that way because you thought he was threatening you. Feeling threatened can trigger emotions in our brain that make extreme behaviours more likely”. Provide sentences to complete, cards/options to pick from.

• Skills building focus

• Clear goals and collaboration help client feel like a partner in therapy, rather than opponent

• Consider joint focus on a task with clients – as this feels less intensely personal

• Disconfirm their expectation that you are dismissive of ‘weakness’ by normalising their reactions rather than gushing with strong expressions of sympathy

• Don’t assume they need to express their emotions or confront their denial for treatment to be successful

• Consider group work to normalise help seeking position

• In 1:1 work, consider one step removed discussion “if someone feels threatened when they are growing up, how might it affect their adult relationships?”

• Explore feelings indirectly through stories/metaphors/externalising (roads, bridges, castles etc)

CASE EXAMPLES

• Robyn – 17yrs

• Early experiences: Alcoholic mother, supervised contact only, cared for by

hostile grandmother, father critical - in and out of prison.

• Current context: Starts college, struggling to develop peer relationships, missing

and obsessing over teachers from school, feeling lonely, isolated and angry

• Symptoms: Low, angry, emotional, thoughts about self harm, feelings of

worthlessness, extreme interpersonal sensitivity, body dysmorphic

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CASE EXAMPLES

• Robyn

• Clues about attachment style:

• Interpersonally sensitive – very easily hurt, offended and let down by others

• Struggles with endings – very upset at the end of each session (fear of

abandonment?)

• Often angry at me (“You don’t care”, “You’re a shit therapist”)

• Struggles to regulate emotions – intense distress expressed

• Pervasive interpersonal difficulties

• What attachment style might apply to Robyn? 51

CASE EXAMPLES

• How might attachment ideas inform how I work with this client?

• What IPT strategies might be useful with Robyn?

• Focus Area strategies

• General Strategies

52

CASE EXAMPLES

• My Approach:

• Think carefully about how I function as a secure base for her (consistent, regular and bounderiedcontact, balanced with some flexibility)

• Validating and attuned – noticing, naming and validating emotional states

• Using a mentalizing approach – sharing what’s in my head and wondering about what’s in hers

• Sharing how her actions effect my emotional state

• Explicit about ending

• Identifying problematic relationship patterns and expectations, and link to early relationship experiences – validate her difficulties but also highlight the harm they cause her

• Notice interpersonal patterns between us and use to understand broader relationship issues

• Communication skills training and practice

• Not trying to resolve attachment style in 16 sessions – BUT trying to increase insight into IP triggers, increase mentalization capacity – how her actions impact others, and teach skills to help strengthen and steady relationships.

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THE SENSITIVITY CYCLE

LEARNING FROM MISTAKES

• Managing frustration – I notice strong emotions when working with some clients with strong sensitivity patterns – I

notice thoughts such as:

• “But why did you do that – it’s so obvious that would cause problems?”

• “I think your mother has a point – you really can’t be trusted to go out!”

• “I really don’t think you are trying hard enough – you’re bringing this on yourself”

• I must search for validating and compassionate interpretations of clients’ actions and feelings – make sense of their IP

difficulties in the context of their history

• Check in with who I am ‘siding’ with – if not the client, then something is wrong – e.g. recent school refusal of a client

• Remind myself of the client’s reduced mentalization capacity when emotionally triggered – think about how I can help

them gain better insight into the impact of their actions on others – e.g. reverse role play activities

• Develop the sensitivity cycle as early as possible – use this to make sense of the clients attacks/hostilities, whilst also

acknowledging my own fallibilities

• Re-assess assumptions about ‘manipulation’

AMBIVALENT ATTACHMENT STYLES IN THE THERAPY ROOM

• Ambivalent client

• Fears separation – endings!

• Seek proximity and care/attention =

Inclined to dramatize problem

• Can be experienced as ‘irritating’ or

‘manipulating’ = reduced empathy

• Therapist can feel nervous of “slipping

up”. Mutually unsatisfying experience.

• Likely to have lots of service

involvement.

• You will feel as if the goal posts/focus

are constantly moving and that you

struggle to make progress.

client

tasktherapist

TYPE C – SUPPORTING ENGAGEMENT

• Set and maintain clear and consistent boundaries regarding

• Your contact with the client

• What you talk about in session (self-disclosure)

• Use supervision to help you think about your own attachment style and how these clients might effect you

• Give clients ownership of their solutions as much as possible to help develop their self-esteem and gradually reduce their dependency on you (note - they don’t need us as much as they tell us they do!)

• Validate their expressed level of need whilst also being a cheerleader - acknowledging their resilience and inspiring confidence that they can do this on their own!

• Rupture/repair experience may be a particularly powerful therapeutic process

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ADAPTING THERAPY STYLE TO MEET ATTACHMENT NEEDS: AMBIVALENT

ATTACHMENT

Meeting the need for emotional support

• The challenge: continuous vigilance of therapist letting them down and chaotic communication style.

• The balance to strike: acknowledge the experience of suffering and the need for emotional support, but without aligning with the sense of disaster as this will intensify the client’s feeling of insecurity and fear that the situation will end badly

• Top tips:

• Be extra clear about what you can provide – don’t promise what you can’t keep. The marathon metaphor – prepare for ending without having reached the finish line

• The client will have a lot to tell – allow some flexibility for this narrative

• If you are too business-like or insist on narrow, predefined agenda they will not feel heard/taken seriously and will experience you as cold and unengaged. They will then test your trustworthiness more!

• Signal empathy and compassion by summarising and showing you have heard them

• Some clients may be more angry – don’t fight back. Recognise the anxiety and anger behind controlling behaviours by keeping in m ind this is fuelled by their underlying feeling of powerlessness and fear of disappointment

• Plan transitions, breaks, endings very carefully

• Transitional objects between sessions? Diaries, letters, grounding objects

INTERESTING STUDIES

• Cryanowski et al. (2002) studied attachment style in 162 women undergoing treatment for recurrent depression. Using a self report measure of attachment style, 42.6% were classified as fearful, 21.6% as secure, 20.4% as pre-occupied and 14.4% as dismissive. Attachment style did not effect treatment response – 53.7% across all patients responded to 24 weeks of IPT, with no significance difference across groups. Of those that did respond to treatment, those with a secure attachment style responded quicker compared to those with a Fearful style.

• McBride et al. (2006) compared treatment outcome for IPT and CBT, and how attachment anxiety and avoidance moderated this. 56 Participants with major depression. Main finding was that clients with higher attachment avoidance did significantly better in CBT than IPT.

• Ravitz et al (2008) discusses the usefulness of attachment theory for understanding depression and the usefulness of IPT. Case examples are used to discuss this relationship.

• Constantino et al (2013) found that of 95 participants with depression treated with IPT, those most likely to remit has lower levels of fearful attachment.

• Smith et al. (2012) looked at the influence of attachment style and therapeutic alliance on treatment outcomes for 70 depressed women with a history of childhood sexual abuse in IPT or TAU. Avoidant attachment and weaker alliance was shown to influence worse outcomes. Alliance did not mediate the relationship between attachment avoidance and worse outcome.

• Gunlick-Stoessel et al. (2017) looked at self reported changes in attachment anxiety and avoidance for 40 depressed adolescents treated with IPT. Both anxiety and avoidance ratings reduced by the end of treatment, and this correlated with a reduction in depression scores. Clients with higher baseline avoidant scores had better outcomes in depression with IPT

REFERENCES

• MDS Ainsworth, SM Bell, DF Stayton. (1974) Infant-mother attachment and social development: Socialization as a product of

reciprocal responsiveness to signals.

• Fraley, C. (2018) http://labs.psychology.illinois.edu/~rcfraley/attachment.htm

• Levy, K.N. & Johnson, B.N (2019) Attachment and psychotherapy: Implications from empirical research. Canadian

Psychology/psychologie

• George, Kaplan & Main (1996) Adult Attachment Interview. http://library.allanschore.com/docs/AAIProtocol.pdf

• P Ravitz, R Maunder, C McBride (2008) Attachment, contemporary interpersonal theory and IPT: An integration of theoretical, clinical,

and empirical perspectives - Journal of Contemporary Psychotherapy

• Choi-Kain, L.W. & Gunderson, J.G (2008) Mentalization: Ontogeny, assessment, and application in the treatment of borderline personality

disorder. American Journal of Psychiatry

• Clarkin, J.F., Levy, K.N., Lenzenweger, M.F. & Kernberg, O.F. (2007). Evaluating three treatments for borderline personality

disorder: A multiwave study. American Journal of Psychiatry

QUESTIONS?