Client attachment and change in mental health during psychotherapy.

In the current study, we used a naturalistic design to examine how client attachment orientations affect changes in client mental health over the course of treatment. We evaluated session-by-session changes in overall maladjustment levels (derived from the Outcome Questionnaire 45.2) in a sample of 105 adult clients who were seeking therapy at a large, university-based, outpatient psychology training clinic. The primary goal of this study was to investigate how client attachment orientations affected patterns of change in client overall maladjustment scores across time. Because previous findings have suggested that client attachment orientations may be associated with different patterns or differential rates of change, beyond linear changes, we also extended previous research by testing more complex models involving quadratic and cubic changes over the course of therapy. Multilevel modeling analysis revealed that client overall maladjustment scores significantly improved throughout therapy. Results further indicated that client attachment anxiety predicted change in maladjustment during therapy. Attachment avoidance did not predict change in symptoms. With respect to attachment anxiety, we found different patterns of recovery or symptom change throughout therapy for clients with high versus low attachment anxiety. Clients low in attachment anxiety showed consistent improvements and those high in attachment anxiety exhibited low levels of therapeutic change throughout the middle of therapy despite their overall improvements. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Client perfectionism and psychological symptoms throughout psychotherapy.

Objective: Given the psychological issues experienced by individuals high in perfectionistic concerns (maladaptive perfectionism), or a feeling as if one is never good enough, and discrepancies in the literature as to whether these individuals experience benefits from therapy, it is imperative that research examine whether perfectionism actually improves throughout therapy. The current study improves upon past research by examining changes in perfectionism (both perfectionistic concerns and strivings) throughout therapy, rather than simply measuring perfectionism at pre- and post-therapy. This study also investigates how these changes in perfectionism, if they exist, impact changes in psychological symptoms. Methods: In total, 153 clients at a psychology training clinic in which a general treatment paradigm was implemented completed the Short Almost Perfect Scale (SAPS; Rice et al., 2014) and Outcome Questionnaire (OQ-45.2; Lambert et al., 1996) prior to intake and sessions 1, 3, and 5. Results and Conclusions: Multilevel modeling results revealed that there were significant improvements in perfectionistic concerns and symptoms although, as expected, no significant changes in perfectionistic strivings were observed. Additionally, there was a trend effect for changes in perfectionistic concerns being associated with changes in symptoms. Further, results of latent difference score analyses revealed that changes in symptoms throughout therapy preceded changes in perfectionistic concerns. Clinical and methodological significance of this article: This study uses multilevel modeling (MLM) and latent difference score analyses to assess changes in perfectionism throughout therapy, whether they are associated with changes in symptoms, and whether changes in perfectionism precede changes in symptoms, or vice versa. To date, there have been discrepancies in the literature as to whether perfectionism improves throughout therapy, and most of these have only measured perfectionism at pre- and post-therapy. This study is an improvement over past studies as it measures perfectionism throughout therapy which has implications for therapy work with perfectionistic clients.

Pseudosecure vs. individuated-secure client attachment to therapist: Implications for therapy process and outcome.

OBJECTIVE: We differentiated two hypothesized client subtypes: (a) Pseudosecure clients have high Client Attachment to Therapist Scale (CATS) Secure and high CATS Preoccupied scores, tend to idealize their therapist, and exhibit maladaptive dependency; (b) Individuated-secure clients combine high Secure with low Preoccupied scores and function more autonomously. Clients who, despite insecure attachment to others, "earn" individuated-secure attachment to their therapist benefit most from therapy. METHOD: We examined regression suppressor effects by reanalyzing raw data from four published studies. If pseudosecure attachment is present, when covariance between CATS Secure and Preoccupied scores is removed, residual Secure scores should be significantly better predictors of process/outcome indicators than raw Secure scores. RESULTS: Suppressor effects were observed in eight of nine analyses. Two were statistically significant. Earned individuated-secure attachment predicted improvement in interpersonal relationship symptoms, but only for clients with Avoidant pre-therapy attachment patterns. Finally, significant meta-analytic effect size estimates were obtained for CATS subscales, Secure r = .274 (95% CI = .177, .366), Avoidant, r = -.296 (95% CI = -.392, -193), and Preoccupied, r = -.192 (95% CI = -.289, -.092). CONCLUSIONS: Clients with pre-therapy Avoidant attachment who nevertheless "earn" individuated-secure attachment to their therapist appear to benefit more from therapy.

Perfectionism affects change in psychological symptoms.

The primary goal of this study was to examine how perfectionism affects psychological symptoms during the course of treatment. We examined session-by-session symptom changes in a sample of 105 adult clients who presented for counseling at a psychology training clinic housed at a large Midwestern university in the United States. Using a recently developed measure of perfectionism (Short Almost Perfect Scale [SAPS]) that possesses good psychometric features, we were able to investigate effects of both maladaptive (high self-criticism) and adaptive (high standards with low self-criticism) perfectionistic characteristics on indicators of personal and interpersonal psychological distress across time. Multilevel modeling analyses indicated that both symptomatic distress and interpersonal problems improved over the course of therapy. Maladaptive perfectionism was associated with higher levels of interpersonal problems and distress at the outset of therapy, and related differentially to change patterns in symptom distress and interpersonal problems over the course of treatment. Maladaptive perfectionism, however, was not related to level of symptoms at the end of therapy. Adaptive perfectionistic characteristics were associated with fewer interpersonal problems at the beginning and end of therapy. Results suggest the value of assessing perfectionistic characteristics at the onset of treatment, even for clients not presenting with obvious concerns linked to such individual differences.

Guidelines for cognitive behavioral training within doctoral psychology programs in the United States: report of the Inter-organizational Task Force on Cognitive and Behavioral Psychology Doctoral Education.

The Association for Behavioral and Cognitive Therapies initiated an interorganizational task force to develop guidelines for integrated education and training in cognitive and behavioral psychology at the doctoral level in the United States. Fifteen task force members representing 16 professional associations participated in a year-long series of conferences, and developed a consensus on optimal doctoral education and training in cognitive and behavioral psychology. The recommendations assume solid foundational training that is typical within applied psychology areas such as clinical and counseling psychology programs located in the United States. This article details the background, assumptions, and resulting recommendations specific to doctoral education and training in cognitive and behavioral psychology, including competencies expected in the areas of ethics, research, and practice.

Disentangling the effects of depression symptoms and adult attachment on emotional disclosure.

Individuals with high levels of depression symptoms and individuals with insecure attachment orientations have been shown to limit their use of emotional disclosure as a means of emotion regulation. However, little is known about how depression symptoms and insecure attachment orientations might jointly predict whether individuals engage in emotional disclosure. The authors addressed this question using both inter- and intraindividual approaches. College students (N = 121) completed measures of depression symptoms, adult attachment orientation, and generalized disclosure tendencies. To obtain an intraindividual measure of emotional disclosure, participants also completed an online daily diary in which they rated the intensity of the day's most unpleasant event and their disclosure of that event for 7 days. Results indicated that depression symptoms were negatively related to generalized disclosure tendencies and to intraindividual daily intensity-disclosure slopes. Attachment avoidance was negatively related to both generalized disclosure tendencies and to daily disclosure, and attachment anxiety moderated the relation between daily event intensity and disclosure. The authors discuss the implications for theory and counseling psychology practice.

Client attachment orientations, working alliances, and responses to therapy: a psychology training clinic study.

The authors examined the associations between client attachment orientations, working alliance, and progress in therapy. Ninety-five clients at two university-based training clinics completed measures of adult attachment, attachment to therapist, and working alliance immediately preceding the third counseling session with therapists-in-training. A standardized measure of progress in therapy was administered at intake, third counseling session, and termination. Hierarchical linear modeling findings indicated that stronger working alliances and secure attachment to therapist were significantly associated with greater reductions in client distress over time. Higher levels of adult attachment anxiety were significantly associated with greater distress ratings at the outset of treatment. Directions for future research and suggestions for developing therapeutic relationships in the context of specific client attachment orientations are discussed.

Respective contributions of therapist and client adult attachment orientations to the development of the early working alliance: a preliminary growth modeling study.

The authors investigated the temporal relationship between client and therapist attachment orientations and early working alliance. Attachment was measured by self-report after the 1st session of therapy. The working alliance ratings were completed after the 1st, 4th, and 7th therapy sessions. Hierarchical linear modeling results indicated that anxiously attached therapists had a significant positive effect on the client working alliances after the 1st session but significant negative effects over time. No other therapist or client attachment variables or related interactions had a significant effect on client working alliance ratings. Results also indicated that time was a significant positive predictor of client working alliance ratings.