According toattachment theory, patients may benefit most from a treatment condition that is opposite (contradictory) to their characteristic level of activation of the attachment system (Mallinckrodt, 2010).
Thus, patients with higher levels ofattachment anxietyare theorized to benefit most from treatments where the main mechanism of change challenges their maladaptive interpersonal behavior of exaggerated proximity seeking (Daly & Mallinckrodt, 2009), such as supportive-expressive therapy (Luborsky et al., 1995).
By contrast, patients with higher levels ofattachment avoidanceare theorized to benefit most from treatments where the main mechanism of change creates emotional closeness in the therapeutic alliance (Daly & Mallinckrodt, 2009), such as supportive therapy (Leibovich et al., 2019).
Key Points
Rationale
Previous research shows hundreds of effective treatments for depression exist, but there is little evidence on which works best for which patients (Cuijpers, 2017).
Tailoring treatment based on pretreatment characteristics could optimize outcomes in a precision medicine approach (National Institute of Mental Health, 2015).
Attachment orientationis a promising moderator, but past studies show mixed results (Tasca et al., 2006; Bernecker et al., 2016).
This RCT tests an a priori hypothesis that patients’ attachment anxiety and avoidance moderate outcomes of SET versus ST (Zilcha-Mano et al., 2018).
Method
One hundred patients with major depressive disorder were randomly assigned to 16 weeks of supportive-expressive therapy (SET) or supportive therapy (ST). SET combines supportive and expressive techniques, while ST uses supportive techniques only.
Sample
The sample was 57% female, with a mean age of 31.2 years. Most participants were employed and had some past treatment. 71% had psychiatric comorbidities.
Statistical Analysis
Multilevel models tested interaction effects between treatment condition, time, and attachment dimensions on HRSD scores. Response was defined as ≥50% HRSD reduction or final score ≤9. Remission was HRSD<8.
Results
Insight
So, while the treatments generally performed similarly, matching patients to the therapy style that contradicted their attachment issues (anxious or disorganized) boosted treatment efficacy. The findings support using attachment orientation to personalize treatment selections.
Strengths
Limitations
Clinical Implications
Tailoring depression treatment based on patients’ pretreatment interpersonal attachment style can improve outcomes. Especially for patients with high attachment anxiety or disorganized attachment tendencies, combining supportive and expressive therapies had better results than supportive therapy alone.
This supports attachment theory’s view that “opposites attract” – matching patients to treatments contradicting their attachment tendencies stimulates more change.
The idea that “opposites attract” refers to a conceptual model in attachment theory that patients may benefit most from a treatment approach that contradicts or challenges their characteristic attachment tendencies.
For patients high in attachment anxiety, who tend to excessively seek closeness and reassurance from others, attachment theory suggests they would benefit from a treatment that pushes them to be more independent and confronts their anxiety-driven interpersonal patterns. This contradicts their natural inclination.
Similarly, avoidantly attached patients who downplay emotional needs and distance themselves from others are theorized to benefit most from a warm, supportive therapy relationship that draws them into more closeness – the opposite of their avoidance tendencies.
Matching patients to a therapeutic experience “opposite” to their attachment leanings, it forces them to stretch beyond their comfort zones interpersonally and develops new mental capacities.
Activating their attachment system in unnatural ways stimulates more change than approaches that align with and reinforce their existing relational habits.
The findings in this study support this – patients high in attachment anxiety did better in expressive therapy confronting their anxiety as opposed to supportive therapy aligning with their need for reassurance. The “opposites attract” principle seems to promote therapeutic gains.
References
Cuijpers, P. (2017). Four decades of outcome research on psychotherapies for adult depression: An overview of a series of meta-analyses.Canadian Psychology, 58(1), 7-19.https://doi.org/10.1037/cap0000096
Daly, K. D., & Mallinckrodt, B. (2009). Experienced therapists’ approach to psychotherapy for adults with attachment avoidance or attachment anxiety.Journal of Counseling Psychology, 56(4), 549–563.https://doi.org/10.1037/a0016695
Leibovich, L., Nof, A., Auerbach-Barber, S., & Zilcha-Mano, S. (2018). A practical clinical suggestion for strengthening the alliance based on a supportive-expressive framework.Psychotherapy: Theory, Research, & Practice, 55(3), 231-240.https://doi.org/10.1037/pst0000195
Luborsky, L., Mark, D., Hole, H. V., Popp, C., Goldsmith, B., & Cacciola, J. (1995).Supportive-expressive dynamic psychotherapy of depression: A time-limited version(pp. 41–83). Basic Books.
Mallinckrodt, B. (2010). The psychotherapy relationship as attachment: Evidence and implications.Journal of Social and Personal Relationships, 27(2), 262–270.https://doi.org/10.1177/0265407509360905
National Institute of Mental Health. (2015). National Institute of Mental Health strategic plan for research.https://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml
Zilcha-Mano, S., Dolev, T., Leibovich, L., & Barber, J. P. (2018). Identifying the most suitable treatment for depression based on patients’ attachment: Study protocol for a randomized controlled trial of supportive-expressive vs. supportive treatments.BMC psychiatry, 18(1), 1-8.https://doi.org/10.1186/s12888-018-1934-1
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Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
