Copyright 1995 by the American Psychological Association, Inc. 0022-0167/95/S3.00

Journal of Counseling Psychology 1995, Vol. 42, No. 3, 307-317

Attachment Patterns in the Psychotherapy Relationship: Development of the Client Attachment to Therapist Scale Diana L. Gantt

Brent Mallinckrodt

Laurel Hill Center, Eugene, Oregon

University of Oregon

Helen M. Coble The Child Center, Springfield, Oregon A panel of 9 therapists generated items for an instrument designed to measure the psychotherapy relationship from the perspective of attachment theory. The initial version of the Client Attachment to Therapist Scale (CATS) contained 100 items that were administered at 4 counseling agencies in survey packets to 138 clients who had completed at least 5 sessions with their therapists. Factor analysis suggested that 36 items loaded on 3 subscales, which we labeled Secure, kvoidant-Fearful, and Preoccupied-Merger. CATS factors correlated in expected directions with survey measures of object relations, client-rated working alliance, social self-efficacy, and adult attachment. Cluster analysis identified 4 types of client attachment. Significant differences in social competencies (object relations, etc.) were evident across types of attachment. Implications of attachment patterns for the understanding of client transference are discussed.

Attachment theory was originally developed to explain the behavioral and emotional responses that keep young children and their caregivers in close physical proximity (Bowlby, 1969). From this foundation, attachment theory offers an explanation for responses to separation and loss (Bowlby, 1973) and the development of emotional attachments after infancy (Ainsworth, 1989; Bowlby, 1977). In an optimal attachment bond, the caregiver provides a comforting presence for the child that reduces anxiety and promotes feelings of security. From this secure base, the child is able to explore the physical and social environment (Bowlby, 1969, 1988). In Ainsworth's pioneering studies of attachment (Ainsworth, Blehar, Waters, & Wall, 1978), in sequential phases of a laboratory observation, children explored a novel play environment in the presence of their mother and were then observed during a brief separation from their mother, exposure to a stranger, and reunion with their mother. Three patterns of attachment were identified. Infants who displayed the secure pattern freely explored in their mother's

presence, showed some anxiety upon separation, and were easily comforted upon reunion. Infants with the anxiousambivalent pattern were excessively anxious, angry, and clinging to an extent that interfered with exploration, distressed during separation, and difficult to comfort upon reunion. Anxious-avoidant infants showed little interest in their mother and little strong affect throughout the observation. These attachment patterns have been confirmed in subsequent studies including in-home observations (Egeland & Farber, 1984; Egeland & Sroufe, 1981) and are thought to result from differences in consistency of caregivers' responses to the infant's physical and emotional needs. Secure attachment may be promoted by caregivers who are generally responsive. Ambivalent attachments may develop when caregivers respond inconsistently, and avoidant attachments may develop when caregivers are consistently unresponsive and emotionally unavailable. Early attachment experiences are thought to become internalized, affecting the development of the child's concept of self and expectations about others (Bowlby, 1977; Bretherton, 1985). A young child's working model of self involves beliefs about whether she or he is generally the sort of person worthy of care and deserving of help from others versus being unworthy of help and comfort. The child's working model of others involves generalized expectations that caregivers will be responsive, helpful, and nurturing versus unresponsive, aloof, and possibly harmful. The term working models is used because in early childhood internal representations can be revised as new attachments are encountered. However, working models become increasingly resistant to change as development proceeds, because new information that does not fit into existing structures is difficult to process and tends to be defensively excluded (Bowlby 1969, 1973; Bretherton, 1985). Beliefs about self

Brent Mallinckrodt, Counseling Psychology Program, University of Oregon; Diana L. Gantt, Laurel Hill Center, Eugene, Oregon; Helen M. Coble, The Child Center, Springfield, Oregon. Diana L. Gantt is now at the Providence Medical Center, Portland, Oregon. We gratefully acknowledge cooperation of the staff and clients of the DeBusk Center, the University of Oregon Counseling Center, the Lane Community College Counseling Center, and the Eugene Clinic. We also thank the students at the University of Wisconsin—Madison and the students, staff, and faculty at the University of Missouri—Columbia who made helpful suggestions about the interpretation of our results. Correspondence concerning this article should be addressed to Brent Mallinckrodt, Counseling Psychology Program, College of Education, University of Oregon, Eugene, Oregon 97403. 307

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and others formed through early attachment experience become an increasingly dominant part of a child's interpersonal style as the child brings working models to bear on new relationships (Bowlby, 1988). The attachment system established in childhood continues to have a major influence on adult social relationships (for reviews, see Coble, Gantt, & Mallinckrodt, in press; Hazan & Shaver, 1994) and may be activated by any close, intimate relationship that evokes the potential for love, security, and comfort, including friendship, kinship, romantic partnership, and the therapeutic alliance (Ainsworth, 1989). Bowlby (1988) argued that the psychotherapy relationship contains many features which activate an adult client's ingrained attachment expectations and behaviors. Similar to a parent or caregiver, the therapist offers emotional availability, a comforting presence, affect regulation, and a secure base from which to explore inner and outer worlds (Pistole, 1989). Thus, the developing therapeutic relationship may be seen as a specialized form of adult attachment, which is strongly influenced by a client's childhood attachment experiences (Bowlby, 1988). Expectations about the relationship are influenced by the same working models of self and others that a client applies to all close personal relationships.

of clients' attachment to their therapists. Components of existing measures—for example, the Bond subscale of the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989)—no doubt capture an important part of this attachment relationship. However, because the development of these measures was not explicitly guided by attachment theory, important components may be missing from the formulation. Therefore, the purpose of this study was to develop and validate a measure that assesses client feelings and attitudes toward the counselor from an attachment perspective. Clients' capacity to form positive, secure attachments to their therapists should be related to clients' capacity for healthy object relations (Ainsworth, 1969; Diamond & Blatt, 1994), clients' capacity for attachment in adulthood (Bowlby, 1988), the quality of the working alliance (Henry & Strupp, 1994; Mallinckrodt, 1991), and the level of basic social competencies (Mallinckrodt, 1992; Mallinckrodt, Coble, & Gantt, 1995). Accordingly, we expected that a valid measure of clients' attachment to their therapists would be significantly correlated with measures of these constructs.

Thus, attachment theory concepts can provide a useful new perspective on psychotherapy process. In therapy, the client reexperiences a primary attachment, reproducing with the therapist parts of an old and usually unsatisfactory relationship (Jones, 1983). When a client reenacts attachment patterns in the therapeutic relationship, the therapist gains access to the client's working models. As the therapist and client explore their relationship and the client's relationships outside therapy, the client's working models become conscious and subject to challenge and change (Sperling & Lyons, 1994). The therapist acts as an empathic and emotionally available attachment figure, encouraging an examination of chronic dysfunctional patterns in relating to others. In successful cases, a secure attachment relationship is eventually formed with the therapist, contributing to a corrective emotional experience for the client (Jones, 1983). Recently, researchers have undertaken new applications of attachment theory to understand psychotherapy processes. Bartholomew and Horowitz (1991) developed a four-category model of adult attachment styles derived from combinations of positive and negative working models of self and others. In subsequent research, clients with different attachment styles were found to exhibit different patterns of interpersonal problems. These problem areas, in turn, were found to differ markedly in how amenable they were to change through brief dynamic psychotherapy (Horowitz, Rosenberg, & Bartholomew, 1993). Client memories of their early emotional bonds with parents have also been found to be significantly associated with client ratings of the working alliance (Mallinckrodt, 1991; Mallinckrodt, Coble, & Gantt, 1995). Although these studies have used concepts from attachment theory, we could locate no previous research that conceptualized the therapeutic relationship from an attachment perspective and that attempted to measure the quality

Method

Instrument Development Nine experienced therapists (3 men and 6 women, all EuroAmerican in ethnicity) generated items in the initial development of the Client Attachment to Therapist Scale (CATS). Three were predoctoral interns, and six were psychologists with doctoral degrees with an average of 11.83 years of postgraduate experience (range = 4-39). Participants were staff members of three university counseling centers or faculty members at two counseling psychology programs. Participants completed materials individually at their own convenience. Packets contained a description of the behavior displayed by infants of the attachment types described by Ainsworth and her colleagues (1978), who used the "strange situation" protocol. Participants were then told, Research suggests these patterns may be relatively enduring and may determine, for example, adult patterns of attachment in romantic relationships. We hope to pilot test a measure which would be able to detect patterns of secure, ambivalent, and avoidant attachments of clients to their counselors. Therapists were then directed to generate items for this measure that were statements of opinion to which a client could respond using a Likert-type scale anchored by strongly disagree through strongly agree. The panel generated a total of 143 items, which were pooled with 129 items we had previously developed. Redundant items were removed from the combined pool of 272 items, 8 new items were written, and the wording of approximately 25 items was changed to the negative to minimize response set bias. The resulting initial version of the CATS contained 100 Likert-type items that used a 6-point response scale (see note to Table 1). After pretesting with a panel of eight graduate students to reword unclear items, we began data collection.

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Instrument Validation Participants Clients were solicited for participation during a 3-year period from four counseling agencies, including a university counseling center, a community college counseling center, a hospital-based outpatient clinic, and an in-house training clinic operated by a counseling psychology program accredited by the American Psychological Association. All of the agencies were located in the same community in the Pacific Northwest. Therapists were senior staff, interns, or graduate students in training at the agencies. Completed surveys were received from 138 clients. Of these, 62 (45%) were from the training clinic, 49 (35%) from the university counseling center, 18 (13%) from the hospital clinic, and 9 (6%) from the community college counseling center. The training clinic participated in all 3 years of data collection, the university counseling center participated for 2 years, and both the hospital clinic and community college counseling center participated for only 1 year. Few clients at the training clinic or hospital clinic were college students. Thus, approximately half of the sample were community residents. Both clinics accepted clients for relatively long-term treatment, whereas both counseling centers operated primarily from a brief therapy model. Part of the data from 77 of these clients was reported in a previous publication (Mallinckrodt, Coble, & Gantt, 1995). Our procedures did not allow for a determination of the survey compliance rate, but the 62 clients participating from the training clinic represented 52% of all clients seen for more than five sessions during the data collection period. At the point they were surveyed, clients had completed a median of 10 sessions with their current therapist (range = 5-62). Of the 138 clients, 121 (88%) were women, 15 (11%) were men, and 2 (1%) did not indicate their sex. In 102 dyads, the counselor's sex was known, with 75 (74%) of therapists being women and 27 (26%) men. Mean age of the clients was 32.57 years (SD = 10.86, range = 18-64). Regarding ethnic identification, 122 (88%) of the clients indicated Caucasian, 2 (1%) Hispanic, 2 (1%) Native American, and 12 (10%) indicated "other" or left the item blank.

Instruments In addition to the CATS items, survey packets contained the measures described below. However, the Bell Object Relations and Reality Testing Inventory (BORRTI) was included only during the last 2 years of the data collection period. Thus, only 72 of the 138 clients completed all of the survey measures. Working Alliance Inventory. The WAI (Horvath & Greenberg, 1986, 1989) is a 36-item self-report measure that uses a 7-point fully anchored response scale (1 = never, 7 = always). Only the 36-item client form was used in this study. The WAI consists of three subscales to assess (a) the emotional bond of trust and attachment between counselor and client, (b) the agreement concerning the overall goals of treatment, and (c) the agreement concerning the tasks relevant for achieving these goals. Good construct validity has been established through multitraitmultimethod analyses (Horvath & Greenberg, 1986). Bell Object Relations and Reality Testing Inventory. The BORRTI (Bell, 1991; Bell, Billington, & Becker, 1986) is a self-report measure of ego functioning and object relations. Only the 45 true-false items of the object-relations domain were used in this study. Four subscales measure the following object-relations deficits: Alienation, a lack of basic trust in relationships, inability to attain closeness, and hopelessness about achieving stable and

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satisfying levels of intimacy; Insecure Attachment, painfulness in interpersonal relations, sensitivity to rejection, and excessive concerns about being liked and accepted; Egocentricity, mistrust of the motivations of others, others existing only in relation to oneself, and others being manipulated for one's own aims; and, Social Incompetence, shyness, uncertainty about how to interact with the opposite sex, and inability to make friends. Bell (1991) reported high factorial stability for these four subscales, and internal consistency and split-half reliabilities that ranged from .78 to .90. The BORRTI has demonstrated significant known-groups discriminant validity in tests that compared patients with borderline personality disorder, major affective disorder, schizophrenia, and adult volunteers (Bell, 1991). Adult Attachment Scale (AAS). The AAS (Collins & Read, 1990) consists of 18 items scored on a 5-point scale that ranges from not at all characteristic of me (1) to very characteristic of me (5). Factor analysis identified three subscales of six items each. The Depend subscale measures the extent participants trust others and rely on them to be available if needed. The Close subscale assesses comfort with intimacy and emotional closeness. The Anxiety subscale measures fears of abandonment. Internal consistency reliability (coefficient alpha) and retest reliability after a 2-month interval were greater than .58 for the three subscales (Collins & Read, 1990). Subscale scores were correlated in theoretically expected directions with measures of self-esteem, social behavior, instrumentality, expressiveness, openness, and satisfaction in romantic relationships (Collins & Read, 1990). Self-Efficacy Scale (SES). The SES (Sherer et al., 1982) was selected because it yields a separate measure of "social" selfefficacy that has been suggested as an important component of the ability to establish healthy attachments in adulthood (Coble, Gantt, & Mallinckrodt, in press). Responses to the 23 items of the original SES are made on a 14-point scale, but in the current study a 5-point response format was used (1 = strongly disagree, 5 = strongly agree). Factor analyses identified 17 items that load on the General Self-Efficacy subscale and 6 items that load on the Social SelfEfficacy subscale. Internal consistency (coefficient alpha) of .86 and .71 were obtained for the General Self-Efficacy and the Social Self-Efficacy subscales, respectively. Evidence of construct validity was provided by significant correlations of the General SelfEfficacy and the Social Self-Efficacy subscales in the predicted direction with internal locus of control, interpersonal competency assertiveness, and the Minnesota Multiphasic Personality Inventory Social Introversion Scale 0 (Sherer & Adams, 1983; Sherer et al., 1982).

Procedure Announcements posted in the agencies described the study as a survey of how "emotional bonds formed between persons in childhood with their parents affect preferences for types of relationships as adults, and the types of counseling relationships they develop." As an incentive, participants received a gift certificate worth $3 for a videotape movie rental or movie ticket. Because we felt a minimum amount of contact was necessary for important features of the client-therapist attachment relationship to emerge, clients were asked to participate only after they had completed at least five sessions of individual counseling. To increase variability, clients were allowed to participate no matter how many sessions they had completed beyond the fifth session when data collection began at their counseling agency. Participants completed surveys in their homes and returned gift certificate requests and survey materials in separate prestamped envelopes. Clients were promised complete anonymity and did not label survey materials with any

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personally identifying information. In the last year of data collection, a subsample of 17 consecutive clients who chose to participate at one of the data collection sites provided retest data by completing a second version of the 100-item CATS instrument 2-4 weeks after the initial survey.

Results

Factor Analysis and Item Selection Our first task was to reduce the initial pool of 100 items to a more manageable number and investigate the factor structure of the data. Before we proceeded with a factor analysis, the condition of the data matrix was examined by calculating the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy. This measure indicates the amount of shared variance in the item pool, and may range from zero to one. The initial KMO index for the 100 X 100 matrix was .288, a level considered unacceptable and characteristic of matrices in which some items share little variance with other items in the pool (Kaiser, 1974). This result was not surprising, given our emphasis on creating a diverse pool of items. Output produced by the SPSSX software package indicates items with low "anti-image correlations," that is, those items that are essentially uncorrelated with other items in the pool (Norusis, 1985). Items with the lowest antiimage correlations were removed in stepwise fashion one at a time, until the item pool was reduced to 75 items. Many of the 25 items removed seemed conceptually less related to attachment, generally, than the items that were retained. The KMO index for the 75-item pool was .749, a level considered acceptable (Kaiser, 1974). Bartlett's test for sphericity was also significant, ^ ( 2 , 775, N = 75) = 7829.87, p < .001, indicating that the 75-item matrix was significantly different from a matrix of essentially unrelated items. A ratio of 5-10 participants per item, up to a maximum of 300 participants in total, has been recommended as a minimum acceptable sample size for factor analysis (Tinsley & Tinsley, 1987). The ratio of 1.84 participants per item in this data set falls below this standard. However, an investigation of the effects of sample size demonstrated that virtually the same factor structure resulted from a sample of 14 participants per item (on a 76-item scale) as was obtained from a subsample of 1.3 participants per item (Arrindell & van der Ende, 1985). We decided to proceed with a factor analysis using our sample of 138 clients, recognizing that findings must be considered tentative until replicated with larger samples. A principal-factors analysis using squared multiple correlations for commonality estimates, with oblique rotation to extract nonorthogonal factors, was performed on the 75 items remaining in the pool. A scree test (Cattell, 1966) suggested that three factors with eigenvalues greater than one should be retained. A second principal-factors analysis with oblique rotation was performed with a forced threefactor solution. The resulting three factors accounted for 26%, 7%, and 5% of variance in the data. Items loading greater than .40 on a factor were used to construct the three initial subscales of the CATS, which

contained 29, 24, and 11 items, respectively. The factors seemed readily interpretable as extracted, but our goal, if possible, was to hold the instrument to fewer than 40 items to increase ease of administration. Therefore, items were removed from the three initial subscales if (a) the item seemed conceptually unrelated to other items on the subscale and its removal increased internal consistency (coefficient alpha) of the subscale or (b) the item was highly correlated or seemed redundant with another item on the same subscale. After this screening, a total of 36 items were retained, none of which loaded on more than one subscale greater than .40. The final version of the CATS instrument, together with item loadings, is presented in Table 1. The labels and interpretations of the three subscales are as follows: (a) Secure (14 items), experiencing the therapist as responsive, sensitive, understanding, and emotionally available; feeling hopeful and comforted by the counselor; and feeling encouraged to explore frightening or troubling events; (b) Avoidant-Fearful (12 items), suspicion that the therapist is disapproving, dishonest, and likely to be rejecting if displeased; reluctance to make personal disclosures in therapy; and feeling threatened, shameful, and humiliated in the sessions; (c) Preoccupied-Merger (10 items), longing for more contact and to be "at one" with the therapist, wishing to expand the relationship beyond the bounds of therapy, and preoccupation with the therapist and the therapist's other clients. The stability of the factor structure was investigated by repeating the analysis with principal-components extraction. When items that loaded greater than .40 were examined, the set was identical to that obtained from the principal-factors extraction. Next, the sample was divided into two randomly selected halves. A factor analysis with principal-factors extraction and oblique rotation was performed independently on each half of the sample. Unfortunately, these analyses could not be performed on the complete set of 75 items because half the sample (n = 69) contained fewer participants than items. Instead, the 36 items selected for the final version of the CATS were used. In the first analysis, 2 of the 36 items loaded on factors different than the original analysis with the full sample. In the second split-half analysis, 3 of the 36 items loaded on different factors. Despite the shifting allegiance of some items in the split-half analyses, the factor loadings of the original analysis from the full sample were retained.

Psychometric Properties of the CATS Means and standard deviations for the CATS subscales are contained in Table 2, together with internal consistency and retest reliabilities. The 17 clients who provided retest data completed the second CATS survey an average of 3.24 weeks after completing the first instrument (range = 2.05.14). Internal consistency (coefficient alpha) and retest reliability coefficients (Pearson's product-moment correlations) were greater than .63 for all of the subscales. Regarding subscale correlations, the Avoidant-Fearful and Secure subscales were significantly negatively correlated, whereas

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Table 1

Client Attachment to Therapist Scale (CATS) Items and Subscale Factor Loadings Item no. la 2 5 8 lla 14 17a 20 23 a 26 29 32 34 36

3 6 9a 12 15 18 21 24 27a 30 33 35

Item text Factor 1: Secure (14 items) I don't get enough emotional support from my counselor. My counselor is sensitive to my needs. My counselor is dependable. I feel that somehow things will work out OK for me when I am with my counselor. My counselor isn't giving me enough attention. When I show my feelings, my counselor responds in a helpful way. I don't know how to expect my counselor to react from session to session. I can tell that my counselor enjoys working with me. I resent having to handle problems on my own when my counselor could be more helpful. My counselor helps me to look closely at the frightening or troubling things that have happened to me. My counselor is a comforting presence to me when I am upset. I know my counselor will understand the things that bother me. I feel sure that my counselor will be there if I really need her/ him. When I'm with my counselor, I feel I am his/her highest priority. Factor 2: Avoidant/fearful (12 items) I think my counselor disapproves of me. Talking over my problems with my counselor makes me feel ashamed or foolish. I know I could tell my counselor anything and s/he would not reject me. I don't like to share my feelings with my counselor. I feel humiliated in my counseling sessions. Sometimes I'm afraid that if I don't please my counselor, s/he will reject me. I suspect my counselor probably isn't honest with me. My counselor wants to know more about me than I am comfortable talking about. I feel safe with my counselor. My counselor treats me more like a child than an adult. It's hard for me to trust my counselor. I'm not certain that my counselor is all that concerned about me.

Factor loading —.86 .75 .66 .61 —.59 .59 —.57 .55 -.55 .52 .51 .46 .44 .41

.73 .70 —.70 .65 .64 .63 .63 .60 - .59 .55 .49 .45

Factor 3: Preoccupied/merger (10 items) I yearn to be "at one" with my counselor. .60 I wish my counselor could be with me on a daily basis. .60 I would like my counselor to feel closer to me. .52 I'd like to know more about my counselor as a person. .50 I think about calling my counselor at home. .49 I think about being my counselor's favorite client. .48 I wish there were a way I could spend more time with my .48 counselor. 25 I wish I could do something for my counselor too. .48 28 I wish my counselor were not my counselor so that we could .47 be friends. 31 I often wonder about my counselor's other clients. .40 Note. N = 138. In the interest of promoting further study, other researchers may use this scale without contacting us to obtain prior permission. However, we do ask that researchers send any reports of research findings as soon as available, including those that remain unpublished, to Brent Mallinckrodt. For comparability to the norms published in this study, the CATS should be prefaced with these instructions: "These statements refer to how you currently feel about your counselor. Please try to respond to every item using the scale below to indicate how much you agree or disagree with each statement." Instructions should be followed with this response scale: 1 = strongly disagree, 2 = somewhat disagree, 3 = slightly disagree, 4 = slightly agree, 5 = somewhat agree, 6 = strongly agree. To score the CATS, reverse key (i.e., 6 = 1, 5 = 2, etc.) the six items with negative subscale loadings, then sum the items for each subscale. This procedure will result in higher scores indicating more Secure, Avoidant-Fearful, and Preoccupied-Merger attachments. a Item should be reverse keyed. 4 7 10 13 16 19 22

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Table 2 Psychometric Properties of the Client Attachment to Therapist Scale (CATS) Subscales Property

Secure

AvoidantFearful

PreoccupiedMerger

M 72.86 21.44 26.43 Mdn 76 19 25 SD 10.11 9.26 8.72 Range 14-84 12-72 10-60 Number of items 14 12 10 Skewa (statistical significance) -1.61** 1.71** 1.09** Internal consistency (coefficient alpha) .64 .63 .81 Test-retest reliability .84 .72 .86 Correlations Secure Avoidant-Fearful -.51** Preoccupied-Merger .23** — -.10 3 5-8 sessions' (n = 45) C M 69.13 23.26 25.13 SD 11.69 11.26 6.89 9-15 sessions'1 (n = 44) M 75.04 20.20 26.87 SD 10.25 7.58 8.18 16-62 sessions'" (n = 45) M 73.84 20.82 27.38 SD 7.31 8.41 10.69 Note. N = 134 because of missing data for some CATS subscales. a Statistical skew represents deviation from a normal distribution. Negative skew indicates a larger than expected number of high scores. Positive skew indicates an abundance of low scores. b Norms by length of therapy at time of data collection. c Mean is significantly different than the means for the other two groups of client responses for this subscale. **p < .01.

the Secure and Preoccupied-Merger subscales were positively correlated. Because clients varied considerably with regard to the number of sessions they had completed at the time of data collection, the sample was divided into three groups of approximately equal size on the basis of length of therapy. Table 2 contains the results of analyses of variance (ANOVAs) used to compare means of the three CATS subscales for these three groupings. Comparisons suggested that the Secure subscale scores were significantly different depending on length of therapy, F(2, 135) = 4.26, p < .05. Duncan's multiple-range test, used for follow-up group comparisons, indicated that clients seen for 5-8 sessions at the time of data collection had significantly lower Secure subscale scores than did either of the other two groups seen for a longer period. Perhaps a secure attachment takes relatively longer to develop, or clients with low levels of secure attachment tend not to remain in therapy beyond eight sessions. In any case, these findings suggest that other researchers using the CATS for comparative purposes should use the most appropriate group norms reported in Table 2. Evidence of concurrent validity is reported in Table 3. The pattern of correlations corresponds closely to expectations based on our empirical definitions of the constructs measured by the CATS subscales. Clients who perceived their therapeutic attachment as secure (i.e., high scores on

CATS Secure subscale) were relatively free of object-relations deficits and tended to report positive working alliances. In contrast, clients with high scores on the CATS Avoidant-Fearful subscale, as expected, tended to have much less positive working alliances and broad deficits in object relations. Clients who scored relatively high on the third CATS subscale, Preoccupied-Merger, tended to exhibit object-relations deficits in insecure attachment. It is interesting that these clients tended to rate the bond aspects of their working alliance as positive, but not the task and goal aspects. As expected, the Avoidant-Fearful and the Preoccupied-Merger subscales were negatively correlated with General Self-Efficacy. It is interesting that AvoidantFearful scores, but not Preoccupied-Merger scores, were negatively associated with ratings of self-efficacy for social outcomes. Contrary to expectations, the Secure subscale was not significantly associated with self-efficacy. Correlations with the AAS subscales were less consistently supportive of CATS construct validity. Finally, we conducted a cluster analysis to identify patterns of clients' attachment to their therapists. We used four measures of the therapeutic relationship (the three CATS subscales plus client-rated working alliance) as grouping variables. To eliminate scaling differences, grouping variables were standardized. Cluster analysis begins by calculating a proximity matrix of the squared-Euclidean distance between all pairs of clients for the set of sorting variables.

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Table 3 Correlations of the Client Attachment to Therapist Scale Subscales With Other Measures Measure/subscale

n

M

Working Alliance Inventory Bond 129 70.74 67.93 129 Task 66.24 129 Goal 204.91 129 Total BORRTI Alienation 72 15.93 Insecure Attachment 72 12.30 72 5.78 Egocentricity Social Incompetence 72 6.05 Adult Attachment Scale 19.13 133 Depend Close 133 17.65 16.08 133 Anxiety Self-Efficacy Scale General Self138 57.12 Efficacy Social SelfEfficacy 138 17.63 Note. Sample sizes vary because of missing Testing Inventory. *p 3.81, ps < .01, in all of the measures except for the Close and Anxiety subscales of the AAS and the Social Self-Efficacy subscale. Figure 1 provides a graphic depiction of these differences. Members of the largest cluster (n = 33), which we labeled secure, had positive working alliances and high scores on the CATS Secure subscale. The second, and smallest, cluster, labeled reluctant (n = 6), was similar to the first cluster in scores on the CATS Secure subscale, but scores on the Avoidant-Fearful subscale were much higher for the reluctant cluster than for the secure cluster. The third cluster, labeled avoidant (n = 11), had high scores on the CATS Avoidant-Fearful subscale—as did the reluctant cluster—but unlike the other three clusters, working alliance ratings in the avoidant cluster were very poor. The fourth cluster, labeled merger (n — 18), was distinguished by high scores on the CATS Preoccupied-Merger subscale. The second panel of Figure 1 illustrates the marked object-relations deficits and lower levels of general self-efficacy, which are characteristic of the avoidant and merger clusters and a high willingness to depend on others in adult attachments. It is interesting that although both clusters

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1

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0.6

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15 0.4 rti

0.2

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0

a

Secure (n = 33)

CATS Subscales Secure

InA

Avoidant Fearful

Aln

Ego

Working

Preoccupied Merger

Scl

Reluctant (n = 6)

Close

Alliance

Dep

Avoidant (n = 11)

Anx

GSe

Sse

Figure 1. Profiles of four Client Attachment to Therapist Scale (CATS) clusters regarding therapeutic relationship variables (A) and social-competencies variables (B). Object-relation deficits are measured by the Insecure Attachment (InA), Alienation (Aln), Egocentricity (Ego), and Social Incompetence (Scl) subscales of the Bell Object Relations and Reality Testing Inventory. Adult attachment is measured by the Close, Depend (Dep), and Anxiety (Anx) subscales of the Adult Attachment Scale. Self-efficacy is measured by the General Self-Efficacy (GSe) and the Social Self-Efficacy (SSe) subscales of the Self-Efficacy Scale.

exhibited high Depend scores, members of the avoidant cluster had high object-relations "social incompetence" deficits, whereas members of the merger cluster rated themselves as less socially incompetent. Those in the secure cluster exhibited relatively lower levels of object-relations deficits. Although the reluctant and avoidant clusters had virtually identical scores on the CATS Avoidant-Fearful subscale, the reluctant cluster had much lower levels of object-relations deficits than did the avoidant cluster. Finally, an ANOVA used to test differences in the number of sessions completed at data collection indicated no significant differences in clusters, F(3, 64) = 0.61, p = ns. The mix of male and female clients in each cluster was also not significantly different, ^ ( 3 , n = 66) = 5.98, p = ns.

Discussion The purpose of this study was to develop and validate a measure that assessed the client-therapist relationship from the perspective of attachment theory. A diverse group of experienced therapists participated in developing the measure, and a diverse group of clients participated in validating it. Factor analysis revealed one factor, which seemed to capture client perceptions of secure attachment, that accounted for a sizable amount of variance and two smaller factors, which both seemed to capture more troubled attachments to the therapist. The subscales derived from these factors demonstrated acceptable internal and retest reliability. The overall pattern of correlations with other measures

SPECIAL SECTION: CLIENT ATTACHMENT TO THERAPIST SCALE supports the construct validity of the CATS. The low correlations between CATS subscales, and different patterns of association with other measures, suggest that the subscales measure distinct aspects of clients' attachment relationship to their therapists. Because shared variance with the WAI was relatively low for the second and third CATS subscales, and lower than the variance shared by the WAI subscales with one another, findings suggest that these CATS subscales measure an aspect of the counseling relationship distinct from the working alliance. Just as patterns of attachment have been observed in infants (Ainsworth et al., 1978) and are believed to govern adult attachment (Bartholomew & Horowitz, 1991), we hoped to identify patterns of attachment in psychotherapy. Results of the concurrent validity analyses and cluster analysis suggest that there are distinct patterns in clients' attachment to their therapists. Clients who scored high on the CATS Secure subscale perceived their therapists as emotionally responsive, accepting, and promoting a "secure base" (Bowlby, 1988) from which to explore threatening aspects of their emotional experience. Clients classified in the secure cluster tended to report positive working alliances, good object-relations capacity, and a relatively strong sense of self-efficacy. These clients probably have a highly positive working model of others and a fairly positive working model of self. Clients who scored high on the CATS PreoccupiedMerger subscale, many of whom were classified in the merger cluster, seemed to desire a dissolution of normal boundaries in the therapy relationship. Not only did they wish more frequent and intensely personal contact, but these clients literally wished to be "at one" with their therapists. They also tended to be compulsively preoccupied with the therapist and the therapist's other clients. Clients in the merger cluster reported a high willingness to depend on others and also a number of serious object-relations deficits. The correlations of the CATS Preoccupied-Merger subscale with working alliance dimensions suggest that these clients form a working alliance bond with their therapists much more readily than they come to agreement about the tasks or goals of therapy. It seems likely that clients in the merger cluster have maintained a strongly negative working model of self and a positive working model of others. Clients who scored high on the Avoidant-Fearful subscale tended to distrust their therapists and fear rejection. They were reluctant to cooperate in the self-disclosure tasks of therapy and tended to feel ashamed and humiliated during sessions. This subscale was correlated with objectrelations deficits involving egocentricity, social incompetence, and alienation (a lack of basic trust in relationships and hopelessness about deriving satisfaction from them). Clients in the avoidant cluster scored high on the CATS Avoidant-Fearful subscale and reported the poorest working alliances, but they also exhibited high scores on the AAS Close and Depend subscales and on the BORRTI Social Incompetence subscale. This combination suggests strong yearnings for emotional connection but grave questions about one's ability to establish such a relationship. It seems doubtful that clients with an unambiguously negative

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working model of others would stay voluntarily in therapy for very long. Clients in the avoidant cluster may have a strongly negative working model of self and a negative model of others with some ambivalence. They may experience themselves as generally not likable and most others as potentially dangerous and rejecting. The small number of clients in the reluctant cluster are more difficult to categorize. As with members of the avoidant cluster, they scored high on the CATS AvoidantFearful subscale; but unlike the avoidant cluster, clients classified as reluctant had few object-relations deficits (lower scores than any cluster), relatively positive working alliances, and high scores on the CATS Secure subscale. We chose the label reluctant for this cluster to connote unwillingness to participate in the self-revealing tasks of therapy (measured by the second CATS subscale). Despite this possible hesitance and feelings of humiliation in sessions, these clients nevertheless seemed engaged with their therapists. They reported their therapists as emotionally responsive and their working alliance as fairly strong. It is tempting to speculate that these therapists and clients had somehow managed to "break through" to engage each other, but much more research is needed on this point. An alternative view is that a considerable degree of denial influenced these clients' self-ratings of object-relations deficits and therapy relationships. Taxonomies of personality disorder involving categories such as "compulsive care seeking" and "angry withdrawal" have been developed on the basis of dysfunctional patterns of attachment (West & Sheldon, 1990). Perhaps clients in the merger or avoidant clusters in this study, that is, those with elevated scores on the CATS Preoccupied-Merger or Avoidant-Fearful subscales, manifest significant personality dysfunction. Clients classified in the reluctant cluster in this study may have a relatively positive working model of self, but a negative working model of others (perhaps excluding their therapists). If so, then the four clusters we identified—secure, merger, avoidant, and reluctant—correspond closely to the four types of adult attachment in Bartholomew and Horowitz' (1991) 2 X 2 model, which they termed secure, preoccupied, fearful, and dismissing. Subsequent research suggested that clients with a dismissing attachment style—and thus perhaps those in our reluctant cluster—may benefit least from brief psychotherapy (Horowitz et al., 1993). Other research has suggested that the experience of incestuous sexual abuse interferes with the adult capacity to use social support and form intimate attachments (Mallinckrodt, McCreary, & Robertson, 1995). Sexual abuse survivors among the clients in the current study may have heightened difficulties with forming healthy attachments to their therapists. Working models of self and others, developed through early attachment experiences, may form the basis for a client's fundamental interpersonal orientation, which can be described in terms of the circumplex dimensions of affiliation and dominance and in terms of patterns of adult attachment (Horowitz et al., 1993). Psychotherapeutic transference involves client feelings and perceptions that correctly belong to earlier relationships that are displaced onto the

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therapist (Gelso & Carter, 1994). Viewed from the perspective of attachment theory, transference may be understood as a misperception of the therapist and of the therapeutic relationship resulting from the client's use of long-established working models of self and others to resolve ambiguities in the new caregiving (therapeutic) attachment and to anticipate the motives and behavior of the new attachment figure (therapist). Thus, to the extent that the CATS measures misperception of the therapeutic relationship, subscale scores may be influenced by client transference. This possibility is intriguing, but much more research is needed to relate patterns of attachment with a therapist to general patterns of adult attachment. A number of important limitations in this study should be noted. All measures were self-report, which introduces the possibility that correlations are inflated and results biased because of common method variance and response set. More confidence could be placed in the results of the factor analysis if a larger sample had been available. Findings need to be confirmed in new samples. Use of the counselor's ratings of the working alliance would have provided a valuable piece of information not available in this data set. Premature termination undoubtedly influenced our findings, given the evidence that Secure attachment scores were significantly higher in clients who had been seen for eight sessions or more. The small number of male clients and clients representing ethnic diversity limits the generalizability of the findings. Secure attachment between minority clients and their therapists may fail to develop because of clients' quite functional reaction to the therapists' lack of multicultural sensitivity (Coleman, 1994). Although we measured only characteristics of clients, therapists offer the relationship conditions that make an attachment possible, and it would be a serious mistake to attribute difficulty in establishing a secure psychotherapy attachment entirely to client factors. Finally, the CATS taps opinions that clients might be very reluctant to share with their therapists. Clients in this study completed the measure anonymously, a procedure that enhanced reliability of the data for research purposes but that would severely restrict the usefulness of the CATS for clinical purposes in ongoing therapy. Further research is needed to test the psychometric properties of the CATS with other samples of clients. If the CATS is established as a valid and reliable measure, a number of interesting avenues for further study would be opened. Memories of childhood attachment experience associated with each pattern of attachment to therapist could be identified. The dynamics of the unfolding therapy relationship that are characteristic of each type of attachment could be investigated, together with variables such as suitability for brief therapy, anticipated breaches in the working alliance (Safran & Muran, 1995), methods of establishing a productive alliance, and the corrective emotional experiences that are most likely to lead to therapeutic change. Perhaps the process of therapeutic change itself could be tracked as changes over the course of therapy in a client's attachment patterns and flexibility of working models.

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Received July 5, 1994 Revision received December 15, 1994 Accepted December 15, 1994