Bowlby's attachment theory describes characteristic patterns of relating to close others and has important implications for psychotherapy. Attachment patterns have been characterized as secure (healthy interdependence with others), anxious (overdependence on others), and avoidant (difficulty relying on others). We update a previous meta-analysis to determine the association of patient attachment with psychotherapy outcome. Metaanalysis of 36 studies (3,158 patients) suggested that patients with secure attachment pretreatment show better psychotherapy outcome than insecurely attached patients. Further, improvements in attachment security during therapy may coincide with better treatment outcome. Finally, preliminary moderator analyses suggest that those who experience low pretreatment attachment security may find better treatment outcome in therapy that incorporates a focus on interpersonal interactions and close relationships. The article closes with research limitations, diversity considerations, and therapeutic practices.K E Y W O R D S attachment style, meta-analysis, psychotherapy outcome, psychotherapy relationship 1 | INTRODUCTION Attachment theory, originally developed by John Bowlby to explain human bonding, has profound implications for conducting and adapting psychotherapy. The concept of attachment style refers to a person's characteristic ways of relating in intimate relationships with "attachment figures." Attachment style involves one's confidence in the

Personality disorders are highly prevalent, associated with considerable morbidity, and difficult to treat. Intrapersonal and interpersonal difficulties are central to the pathology observed in personality disorders. Attachment theory provides a broad yet parsimonious explanatory framework for understanding the development, maintenance, and treatment of personality pathology. Attachment theory conceptualizes human behaviour in ways consistent with multiple scientific traditions, including evolutionary, developmental, and neuropsychological domains. The relevant literature has focused predominately on borderline personality disorder, although a few studies have examined attachment associations with other personality disorders, such as narcissistic and avoidant personality disorders. The authors first outline attachment theory and discuss assessment of attachment patterns from both developmental and social psychological viewpoints. Next, the authors present empirical support for attachment theory and its associations with personality, including studies of developmental, physiological, neurobiological, and genetic correlates of personality pathology. They then look at psychotherapy research relevant to (a) underlying components of current psychotherapies, (b) the relation between attachment and both therapy process and treatment outcome, and (c) changes in attachment styles as a result of personality disorder treatment. Finally, the authors call for future research to delve deeper into specific relationships between attachment constructs and personality pathology, as well as to address personality disorders more broadly.

Behavior therapy (BT), cognitive-behavior therapy (CBT), and interpersonal psychotherapy (IPT) have each been shown by at least two Type 1 or Type 2 randomized controlled trials, as well as by four meta-analytic reports of the literature, to be effective psychosocial interventions for patients meeting criteria for major depressive disorder (MDD). All three psychosocial treatments have yielded substantial reductions in scores on the two major depression rating scales (the Beck Depression Inventory and the Hamilton Rating Scale for Depression), significant decreases in percentage of patients meeting the criteria for MDD at posttreatment, and substantial maintenance of effects well after treatment has ended. The data for outcomes of psychosocial and pharmacological interventions for major depressive episodes suggest that the two treatment modes are equally efficacious. At least one major study lends strong support for the superior effectiveness of combined psychosocial and pharmacological treatments with severe and chronic depression. Additional recently published data suggest that psychosocial interventions may be as effective as antidepressant medications in the treatment of severely depressed patients.

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