Treatment for Depression Based on Patients’ Attachment Style: A Randomized Controlled Trial

According to attachment 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 of attachment anxiety are 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 of attachment avoidance are 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).

Zilcha-Mano, S., Goldstein, P., Dolev-Amit, T., Ben David-Sela, T., & Barber, J. P. (2021). A randomized controlled trial for identifying the most suitable treatment for depression based on patients’ attachment orientation. Journal of Consulting and Clinical Psychology, 89(12), 985–994. https://doi.org/10.1037/ccp0000696

Key Points

1. This randomized controlled trial (RCT) was the first designed a priori to test if patients’ attachment orientation moderates treatment outcome for depression.
2. Patients with higher attachment anxiety benefited more from supportive-expressive therapy (SET) than supportive therapy (ST).
3. Patients with disorganized attachment (high anxiety and avoidance) also benefited more from SET.
4. The study demonstrates the utility of RCTs designed to test differential treatment effects based on theoretical models of mechanisms of change.

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 orientation is 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.

The primary outcome was depression severity measured by the Hamilton Rating Scale for Depression (HRSD). Pretreatment attachment orientation was assessed with the Experience in Close Relationships scale.

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

• No overall difference emerged between treatments on depression improvement over time.
• As hypothesized, attachment anxiety significantly moderated outcomes, with higher anxiety patients benefiting more from SET (p = .016).
• The disorganized attachment group (high anxiety and avoidance) also benefited more from supportive-expressive therapy SET in sensitivity analyses (p = .04).

Insight

• Overall, supportive therapy (ST) and supportive-expressive therapy (SET) showed equal effectiveness in reducing depression over time.
• However, patients’ attachment anxiety levels did significantly influence which treatment worked better:
  • Patients high in attachment anxiety had better outcomes with SET compared to ST.
  • Patients low in attachment anxiety did equally well in SET and ST.
• In additional analyses, patients with disorganized attachment tendencies (high anxiety AND high avoidance) also benefited more from SET than ST.

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

1. RCT designed a priori to test moderation hypotheses based on theory
2. Manualized treatments with checked adherence
3. Low attrition rate

Limitations

1. Small sample size underpowered for some analyses
2. Participants had low comorbidity rates compared to typical patient populations
3. Findings may not generalize to other treatments or formats like group therapy

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

Bernecker, S. L., Constantino, M. J., Atkinson, L. R., Bagby, R. M., Ravitz, P., & McBride, C. (2016). Attachment style as a moderating influence on the efficacy of cognitive-behavioral and interpersonal psychotherapy for depression: A failure to replicate. Psychotherapy: Theory, Research, & Practice, 53(1), 22-33. https://doi.org/10.1037/pst0000036

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

Tasca, G. A., Ritchie, K., Conrad, G., Balfour, L., Gayton, J., Lybanon, V., & Bissada, H. (2006). Attachment scales predict outcome in a randomized controlled trial of two group therapies for binge eating disorder: An aptitude by treatment interaction. Psychotherapy Research, 16(1), 106-121. https://doi.org/10.1080/10503300500090928

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

Keep Learning

1. How might other interpersonal factors like empathy, mentalization, or therapeutic alliance moderate or mediate treatment effects?
2. Would assessing changes in attachment style over the course of treatment explain more variance in outcomes?
3. What adaptations may improve generalizability to real-world practice vs. controlled trials?
4. How could this attachment framework extend to tailoring treatment for other disorders like anxiety, PTSD, or eating disorders?