Professional Documents
Culture Documents
0022-0167/95/S3.00
Brent Mallinckrodt
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.
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
WisconsinMadison and the students, staff, and faculty at the
University of MissouriColumbia 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.
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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.
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.
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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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
310
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
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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
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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.
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
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<.05. **p<.01.
SD
7.86
9.23
10.23
25.20
Secure
FearfulAvoidant
PreoccupiedMerger
.77**
.80**
.77**
.82**
-.71**
-.62**
-.57**
-.56**
.19*
.09
.15
.07
9.47
-.28*
.42**
.18
4.99
4.08
-.29**
-.28*
.22
.36**
.28*
.16
4.46
-.23*
.46**
.00
2.52
2.64
4.06
.15
.05
-.10
.09
.17
.17
.18*
-.04
-.01
12.08
.15
-.39**
-.31**
6.16
.14
-.28**
-.09
data. BORRTI = Bell Object Relations and Reality
314
o
CO
E 0.8
laxim
=3
0.6
Clusters
15 0.4
rti
0.2
Pro
c
o
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.
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
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316
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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