Client Engagement in Psychotherapy: The Roles of Client and Beginning Therapist Attachment Styles
Creators: Yoskowitz, Nicole Aelise
Publisher: name: Columbia University
Year: 2018
Subjects: Clinical psychology
Psychotherapy
Therapist and patient
Attachment behavior

description: Client engagement in psychotherapy has been identified as a significant component of the therapeutic process, and research has found compelling links to psychotherapy outcomes.  Attachment theory has been used to explore the various domains of client engagement in therapy. Specifically, the development of the therapy relationship and the client’s engagement in therapy can be understood as reflecting how a client forms new relationships in general. The primary aim of this dissertation is to explore how the attachment styles of adult clients and beginning therapists (still in training) influence clients’ engagement in individual psychotherapy, in terms of regularity of attendance, self-disclosure of important/relevant topics to the therapist, and the client’s perception of the working alliance. More specifically, this study explores the roles of client and therapist attachment style in client attendance and client self-disclosure, over and above what is explained by the alliance’s relationship with these other engagement measures. 
      	Data used in this dissertation were collected as part of an ongoing longitudinal study conducted at the Dean Hope Center for Educational and Psychological Services, a community-based outpatient training clinic at Teachers College. Participants were 181 adult individual psychotherapy clients and their masters and doctoral level student-therapists (n = 118). In this study, client and therapist attachment style (attachment avoidance and attachment anxiety) was measured using the Experiences in Close Relationships Scale- Short Form. The client engagement variables were measured using the client-rated Disclosure to Therapists Inventory-IV (client self-disclosure and self-disclosure discrepancy), the client-rated Working Alliance Inventory- Short Form (client-rated alliance), and objective measures of client attendance at scheduled sessions collected from a review of clinic attendance records (session attendance). 
      	Results showed no significant relationship between client or therapist attachment styles, or their interaction, and the client-rated alliance in this sample. Results also indicated no significant relationship between client or therapist attachment styles, or their interaction, and attendance during the initial sessions of therapy, after accounting for any effects of the alliance. However, results did show significant relationships between client and therapist attachment style and attendance in therapy after the initial sessions and self-disclosure discrepancy (extent of self-disclosure based on importance and relevance of topics to the client), after controlling for any effects of the alliance. Specifically, results showed that clients with a more secure attachment style had a higher percentage of attendance after the initial therapy sessions than clients with a more insecure attachment style. In addition, clients whose therapists were higher on attachment anxiety had a lower percentage of attendance after the initial therapy sessions, whereas clients whose therapists were higher in attachment avoidance had a higher percentage of attendance after the initial therapy sessions. Results also showed that clients with higher attachment anxiety showed greater self-disclosure discrepancy, in that they disclosed less to their therapists than was expected based on the salience of topics to clients. There was also a trending interaction between therapist attachment avoidance and client attachment anxiety on self-disclosure discrepancy.
      	Study findings are compared to findings in the literature, and results are discussed in terms of attachment theory. Specific limitations and strengths of the study are then discussed. Implications of the study findings in terms of the development and training of beginning therapists are outlined. Findings in the current study indicating that client and therapist attachment style play a role in client attendance at therapy sessions and client self-disclosure in sessions, point to the need for more research in this area and additional consideration of the relationship between these variables and how they impact the therapeutic process, and ultimately therapy outcome.