Research paper
Adult attachment representation moderates psychotherapy treatment efficacy in clinically depressed inpatients

https://doi.org/10.1016/j.jad.2016.02.024Get rights and content

Highlights

  • We investigated changes in attachment representation in depressed patients.

  • Patients with more attachment security benefited more from the inpatient treatment.

  • Inpatient psychotherapy promotes attachment security and not only symptom reduction.

Abstract

Background

We explored in a sample of clinically depressed patients the influence of attachment security and unresolved trauma on psychotherapeutic outcome as well as changes in attachment representation through psychotherapeutic intervention.

Methods

The sample consisted of 85 women (aged 19–52), 43 clinically depressed patients from a psychosomatic inpatient unit, and 42 healthy control subjects matched for age and education. Average length of hospitalization in the patient group was eight weeks. Attachment representations were assessed with the Adult Attachment Interview at the time of admission (baseline) and at discharge. Depressive symptoms were measured using the PHQ-9 at T1 and T2.

Results

Insecure attachment representations were overrepresented in depressed patients. Treatment effects were moderated by baseline attachment representation: patients with higher attachment security scores at admission benefited more from the inpatient treatment and were less depressed at time of discharge than less secure patients (η2=.07). Generally, attachment security increased (η2=.19) and depressive symptoms decreased (η2=.23) after inpatient psychotherapy treatment in the patient group. No significant effects for unresolved symptoms were found.

Limitations

The study is not a randomized controlled study, but used a quasi-experimental matched control group design with female subjects only.

Conclusions

Our results suggest that attachment representations play a major role in both the development and treatment of clinical depression. Baseline attachment security may influence psychotherapeutic outcome, perhaps through relational factors such as therapeutic working alliance. Inpatient psychotherapy may also need to address psychological issues associated with depression such as attachment insecurity.

Introduction

Childhood trauma and negative attachment experiences have been found to be major risk factors for depression in adulthood. With depressed adult patients, psychotherapy aims at symptom reduction and increase of psychosocial functioning. Empirically, however, little is known about the impact and modification of attachment representation in the process of inpatient psychotherapy. The objective of the present study is to test whether attachment representation and unresolved attachment trauma moderate the psychotherapeutic impact on depressive symptom levels. Furthermore, we examine whether psychotherapy improves the representation of early attachment experiences in the direction of attachment security, and whether it decreases the level of unresolved trauma symptoms.

With a life-time prevalence between 10% and 15% in the general population major depressive disorder is one of the most frequent and debilitating diseases worldwide, with highly adverse impact on the subjects' quality of life in domains such as psychosocial functioning, work productivity, relationship quality, and mortality risk (Lepine and Briley, 2011). Women are at higher risk to suffer from depression than men, with female-male prevalence ratios around 2:1 (Burt and Stein, 2001). Causes of depression are multifaceted and based on a complex interplay of genetic and environmental influences (Karg et al., 2011, Sullivan et al., 2000), yet childhood trauma, insecure attachment and maladaptive relationship patterns have been found to be significant risk factors in the development and perpetuation of depression (Kendler et al., 2004, Wiersma et al., 2009).

John Bowlby, the founder of attachment theory, stressed the importance of early attachment experiences on mental health and conceptualized attachment as a lifespan development concept in order to explain “the many forms of emotional distress and personality disturbance, including anxiety, anger, depression, and emotional detachment, to which unwilling separation and loss give rise” (Bowlby, 1979). In childhood and in adulthood, theory as well as research underlines that differences in internal working models of attachment mirror differences in emotion regulation: While secure individuals are (mostly) effective in emotional regulation when feeling distressed, insecure individuals cope less well with distress. In particular, insecure-dismissing adults tend to deny negative emotions and attachment needs, and insecure-preoccupied adults are overwhelmed by them with maximizing attachment signals as assessed with the Adult Attachment Interview, the AAI (Hesse, 2008, Main et al., 1985). Adults with unresolved attachment representation fail to regulate emotions effectively when talking about an experienced loss or trauma in the AAI (Bakermans-Kranenburg and Van IJzendoorn, 2009, Hesse, 2008). In line with the expectation, unresolved symptoms and unresolved attachments are strongly overrepresented in abused individuals and those suffering from PTSD, but-surprisingly-not in depressed samples. Depressive symptoms seem related to attachment insecurity in a non-systematic manner; they were found to be associated with insecure-dismissing as well as insecure-preoccupied attachment representations (Bakermans-Kranenburg and Van IJzendoorn, 2009). It should be noted that when adult attachment style was assessed via self-report questionnaires in terms of a specific relationship quality or schema, insecure attachment style was strongly linked with depressive symptoms (Marganska et al., 2013, Roelofs et al., 2011), but attachment style and representation are considered different, independent dimensions of adult attachment (Crowell et al., 2008, Roisman et al., 2007). In the current study we focus on attachment representations.

Psychotherapy with its “purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable” (Norcross, 1990, page 218) is highly relevant for the clinical application of attachment: Bowlby (1988) stressed the dynamic nature of internal working models, suggesting that the attachment system displays significant continuity but is also open to modification and change, for instance through psychotherapy, that may help the individual to create a more coherent autobiographical narrative.

The significance of coherence for mental health has been already noted by Freud (1997), who observed that in patients autobiographical narratives “connections-even the ostensible ones-are for the most part incoherent, and the sequence of different events is uncertain" (Freud, 1997, p.10). Empirically, psychotherapy improves narrative coherence about emotionally relevant events (Adler et al., 2013). Fonagy and colleagues (Fonagy et al., 2002, Fonagy et al., 1991b, Fonagy and Target, 2005) extended attachment theory and modern psychoanalytic theory to include the concept of mentalization (Fonagy et al., 1998). Mentalization is strongly linked with attachment and they develop hand in hand (Bowlby, 1988): parents' mindful and sensitive parenting increases both secure attachment and mentalization in a child (Bowlby, 1979, Bowlby, 1988, Fonagy et al., 1991a, Meins et al., 2001, Slade, 2005). Research in clinical adult samples support the link between insecure attachment and poor mentalization, and mentalization-based treatment (MBT) has been applied with some success in the treatment of Borderline Personality disorders (Bateman and Fonagy, 2009). Also other diagnostic patient groups having experienced adverse and/or traumatic interactions with attachment figures may benefit from mentalization-focused psychotherapeutic approaches as mentalization may “buffer” the effect of adverse childhood experiences on mental health (Outcalt et al., 2016), possibly through reflecting on and thus altering internal working models (Bowlby, 1979, Fonagy and Bateman, 2006).

Internal working models can be viewed as relationship or interpersonal schemata (Bretherton and Munholland, 2008), and, although differing in treatment concepts and tools, evidence-based psychotherapies have in common that they aim at interpersonal problems and the revision of maladaptive relationship patterns. In the treatment of nonpsychotic depressive disorders, patients with adverse childhood experiences and trauma have been shown to benefit at least as much from psychotherapy as from pharmacotherapy (Nemeroff et al., 2003).

Most patients with major depressive disorder can be treated in an outpatient setting, but severe and complex cases do not respond to outpatient treatment (Cuijpers et al., 2014) and may need inpatient treatment (Harter et al., 2010). Psychosomatic inpatient treatment programs in Germany are characterized by a strong focus on psychotherapy as the main treatment modality, with outcomes of overall medium to large effect sizes (Liebherz and Rabung, 2013). Specifically for clinically depressed females, Franz et al. (2015) reported in a naturalistic multi-center study including 15 German psychosomatic hospital units robust positive treatment outcomes and invited researchers to further explore predictors of therapeutic effects.

Psychotherapy studies including the AAI indicate that symptom reduction is linked to changes in attachment narratives: in a sample of women suffering from PTSD, unresolved symptoms in the AAI were strongly associated with PTSD avoidant symptoms, and addressing imaginal exposure therapy led to both decreases of unresolved symptoms in the AAI and of PTSD symptoms (Stovall-McClough and Cloitre, 2006). Harari et al. (2009) distinguished in a sample of Dutch veterans with and without PTSD between deployment-related and non-deployment related unresolved symptoms and found deployment-related, but not non-deployment related unresolved symptoms associated with PTSD symptom severity. In a sample of borderline patients comparing transference-focused treatment, dialectical behavior therapy and supportive psychotherapy, transference-focused treatment focusing on attachment themes led to significant increase in attachment security as well as attachment-related metacognition and mentalization capacities (reflective functioning) one year after treatment (Levy et al., 2006), however, no changes in unresolved symptoms were reported. From these reports, it remains unclear whether unresolved symptoms in the AAI are directly linked to clinical symptoms and how symptom improvement is related to changes in unresolved symptomatology. In clinically depressed mothers, parent-child psychotherapy led to both higher reflective functioning in the AAI as well as more positive relationships to their toddlers (Toth et al., 2008, Toth et al., 2006).

Psychotherapy may impact the patient's attachment narratives and therefore move toward a more secure attachment orientation: The therapist as attachment figure assists the patient with his emotional regulation and reflection on past and current attachment relationships, including the one with the therapist – provided that the patient can use the therapist as “secure base” and form a working alliance with the therapist (Bowlby, 1979, Bowlby, 1988; Byng‐Hall, 1995; Dozier and Tyrrell, 1998). Several studies on patients' attachment and therapeutic alliance employing attachment-related self-report assessments reported that patients' greater attachment security is linked with better therapeutic working alliance, while attachment insecurity (anxious and avoidant attachment styles) was associated with lower working alliance (Bernecker et al., 2014, Diener and Monroe, 2011).

So far only one study (Fonagy et al., 1996) systematically involved the AAI in a (psychoanalytically oriented) inpatient psychotherapy setting with nonpsychotic patients suffering from different mental disorders (e.g. affective, personality, eating disorders). Baseline insecure-dismissing patients showed the highest degree of symptom improvement. Furthermore, depressive and dysthymic patients were at baseline mostly preoccupied and unresolved in the AAI (Fonagy et al., 1996). It remained unclear, how symptom reduction was linked to changes in the AAI or how initial attachment status influenced treatment process variables.

In sum, these studies emphasize that attachment theory may facilitate the understanding of psychopathological development and might be also a useful tool to explore differences in treatment process and outcome. The evidence-base is, however, rather poor and more treatment studies are urgently needed. In a sample of depressed females with a carefully matched mentally healthy control group, we explored the impact of and changes in attachment representations assessed with the AAI before and after psychotherapy inpatient treatment. Based on previous studies, we expected that in our depressed sample insecure attachment would be overrepresented at baseline. We also expected a significant decrease in depressive symptomatology after inpatient treatment. Assuming that attachment security is related to better therapeutic working alliance and that unresolved trauma may hinder treatment processes, we expected a) symptom reduction after treatment to be moderated by higher baseline attachment security at time of admission; and b) symptom reduction after treatment to be moderated by lower unresolved symptoms at time of admission. Next, we hypothesized that through addressing interpersonal problems, losses, traumata as well as adverse early attachment experiences in psychotherapy inpatient treatment c) attachment security would increase and unresolved symptoms would decrease. Finally, we explored if potential increases in attachment security and decreases in unresolved symptoms were associated with decreases in depressive symptoms.

Section snippets

Participants and procedure

The total sample consisted of 85 women aged 19–52 (M=30.1 years, SD=9.0 years). 58% (n=49) of the participants had a high school degree, 38% (n=33) secondary education and 4% (n=3) lower secondary education. All participants were Caucasian and fluent in German language. The clinical sample consisted of 43 depressed patients, who were recruited from the inpatient unit of a Department of Psychosomatic Medicine and Psychotherapy in Rhineland-Palatinate, Germany. The control group involved 42

Preliminary analyses

Participant age and duration of treatment (inpatient group) were not associated with attachment classification, F(3,81)=0.30, p=.82, η2=.01, nor with dimensional attachment security, r(85)=0.04, p=.70, or unresolved symptoms, r(85)=0.07, p=.51. As expected, insecure attachment groups were significantly overrepresented in the clinical sample at time of admission (χ2(3, N=85)=33.21, p<.001, φ= 0.63), see Table 1a. Attachment security was significantly lower in the patient than in the control

Discussion

We explored the influence of attachment security and unresolved symptoms on psychotherapeutic outcome and changes in attachment representation through psychotherapeutic intervention in a sample of depressed females. As expected and reported previously, insecure attachment representations were significantly overrepresented in depressed patients compared to age-matched controls. However, contrary to prior findings in depressed samples (Bakermans-Kranenburg and Van IJzendoorn, 2009, Dozier et al.,

Acknowledgments

We would like to express our special thanks to all patients and control subjects for their participation in this study. We also thank the project coordinators Johanna Ottemeyer and Gotje Trojan. Marinus van IJzendoorn and Marian Bakermans-Kranenburg are members of the Leiden Consortium on Individual Development and were supported by the Dutch Ministry of Education, Culture, and Science and the Netherlands Organization for Scientific Research (Gravitation program NWO grant number 024.001.003,

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