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Section 23
Assessing Client-Therapist Attachment

Question 23 | Test | Table of Contents

As part of a larger longitudinal study assessing changes in attachment and symptomatology in borderline patients, we have adapted the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1996) to assess patients and therapists' states of mind with respect to attachment and reflective function in the therapeutic relationship. We have developed an instrument called the Patient-Therapist Adult Attachment Interview or PT-AAI (George, Kaplan, & Main, 1996; Diamond et al., 1999). The first 16 questions of the PT-AAI follow the same format and order as the AAI questions, with minor changes in the wording to fit the context of the patient-therapist relationship. For example, the AAI question, "Why do you think your parents behaved as they did during your childhood?" has been revised to read, "Why do you think your therapist/patient behaves the way he or she does as a therapist/patient?" Similarly, the AAI question, "Is there any particular thing you learned above all else from your childhood relationships?" has been revised to read, "Is there any particular thing you learned above all else from the therapeutic relationship?"

As is the case with the AAI, in the PT-AAI the individual is asked to describe the therapeutic relationship generally, to give five words to describe the therapist or patient, and to support these descriptors with specific examples or incidents. The interview also includes questions about the individual's response to separations from the patient or therapist, about what the individual did when he or she was upset, hurt, or ill in the course of therapy, and about times when the individual felt rejected or threatened by the patient or therapist in the course of treatment. In addition, speakers are asked why they think the patient/ therapist acted the way he or she did in the course of treatment, and to evaluate the effects of psychotherapy. As with the AAI, the interview is designed to "surprise the unconscious" (George et al., 1996, p. 3) by allowing numerous opportunities for the interviewee to elaborate on, contradict, support, or fail to support previous statements or generalizations. We have also added 12 additional questions that further explore the particulars of the patient-therapist relationship. These additional questions are designed to further explore the patients' and therapists' experience and representation of the therapeutic relationship as well as their capacity to mentalize or reflect on that experience. Examples of additional questions include, "How do you think that your patient/therapist feels about you?" and "Do you think of your therapist/patient outside of the therapy?"

As is the case with the AAI, the PT-AAI requires specialized training to administer and score.The PT-AAI is transcribed verbatim for purposes of analysis, using the same transcription rules that apply to the AAI. An attachment classification for the patient and/or therapist is derived from the first 16 questions of the PT-AAI using an adaptation of the four-way Adult Attachment Scoring and Classification System (Diamond, Stovall-McClough, Clarkin, & Levy, 2003; Main & Goldwyn, 1998). The interviews are assigned one of four primary classifications: Secure/Autonomous, Preoccupied, Dismissing, or Cannot Classify. The Unresolved classification is not relevant for the patient-therapist attachment relationship because it assesses the lack of resolution of traumatic abuse and loss of attachment figures. The overall classifications are derived from two classes of subscale ratings:  Experience Scales that are based on the rater's inferences about the individual's experience of the therapist/patient; and State of Mind Scales that assess the individual's organized states of mind with regard to attachment information.

The subscale ratings as well as the overall attachment classifications have been adapted to fit the context of the patient-therapist relationship by Diamond and colleagues (2003). Whereas revision of the State of Mind subscales has necessitated only minor changes in wording, revision of the subscales designed to assess the speaker's experience of the relationship has involved more substantial changes in conceptualization to fit the context of the patient-therapist relationship. For example, the AAI subscale for loving versus unloving behaviors between parent and child has been changed to the PT-AAI subscale of liking versus not-liking; that is, the extent to which the patient and therapist maintain positive feelings of concern, caring, and warmth despite the vicissitudes of the transference. Similarly, the AAI subscale for involving, or the extent to which the parent attempts to involve the child or to seek parenting from the child, has been revised to assess the extent to which patient and therapist seek attention or caretaking from each other in ways that go beyond the frame of the therapeutic relationship.

On the basis of the subscale scores, individuals are assigned to one of the following four categories designed to capture the overall quality of the patient-therapist attachment relationship:
Secure (F). Patients and therapists are classified as secure/autonomous when their interviews show that they value the therapeutic relationship and regard attachment-related experiences within the therapeutic relationship as influential. Patients rated as secure/autonomous are likely to present a believable picture of a therapist serving as a secure base during treatment, or if the therapist did not provide a secure base during treatment, these subjects are still moderately to highly coherent regarding the relationship. Therapists are given a secure/autonomous rating when they are able to provide a believable and coherent picture of the relationship with the patient and demonstrate an open capacity for reflection and thoughtfulness regarding difficult aspects of the relationship, including countertransference reactions. Therapists with secure states of mind also have a strong confidence in their ability to act as a secure base for their patient.

Dismissing (D). Patients and therapists are classified as dismissing when their interviews suggest they are cut off from attachment-related feelings and experiences within the therapeutic relationship. The interviews are characterized by attempts to limit the influence of and feeling about the therapeutic relationship through idealization, devaluation, or disavowal of the relationship. There may also be a disavowal of any imperfection in the patient or therapist in the face of contradictory or unsupportive evidence, or a derogation of the therapeutic relationship, or psychotherapy in general. In these interviews, there are often assertions of independence from or noninvolvement with the patient or therapist. Patients classified with dismissing states of mind with respect to the therapist may present a picture of the therapeutic relationship that is moderate to strongly idealized in that global positive descriptions of the therapy and the therapeutic relationship are not backed up with specific examples or memories of positive experiences (comfort, support, concern, caring, etc.) from the patient or therapist. Similarly, therapists are classified with dismissing states of mind with respect to the patient when they portray the therapeutic relationship and experience as uniformly positive without convincing specific illustrations. Therapists and patients classified as dismissing acknowledge difficulties with the patient or the treatment, but they do so in a cool, off-hand, or matter-of-fact manner that shows little emotional depth or involvement.

Preoccupied (E). Therapists and patients who are classified as preoccupied share an excessive involvement in and preoccupation with the therapeutic relationship beyond what is normative for psychotherapy. Their narratives tend to be confused, unobjective, incoherent, and preoccupied with the therapeutic relationship and/or by past experiences of therapy. Those with preoccupied states of mind usually show a weak and confused sense of personal identity, and they tend to organize their affective life around the therapeutic relationship and the therapeutic interactions. In extreme cases, a patient's preoccupation with the therapeutic relationship can be expressed through dramatic self-destructive and destructive actions designed to elicit the therapist's care and concern or to punish the therapist for imagined slights. Therapists classified as preoccupied are over involved with the patient and his or her progress, sometimes conveying a sense of immersion in the emotional life of the patient beyond the norm for clinicians of most theoretical persuasions. The preoccupied therapist may express the belief that his or her professional reputation depends on the outcome and fate of the treatment, or he or she may report excessive mental preoccupation with the patient and his or her progress.

Cannot Classify (CC). Interviews are categorized as Cannot Classify when the patient or therapist shows evidence of two or more different discourse strategies (Dismissing and Preoccupied), or suddenly and dramatically changes discourse strategy in mid-interview.
- Diamond, Diana, Kenneth Levy, John Clarkin, and Chase Stovall-McClough; Patient-therapist attachment in the treatments of borderline personality disorder; Bulletin of the Menninger Clinic; Summer 2003; Vol. 67 Issue 3

Personal Reflection Exercise #9
The preceding section contained information about assessing client-therapist attachment.  Write three case study examples regarding how you might use the content of this section in your practice.

What are the four categories of patient-therapist attachment on the AAI? To select and enter your answer go to Test

Section 24
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