Attachment and Alliance in the Treatment of Depressed, Sexually Abused Women

Abstract

Background Depression among women with sexual abuse histories is less treatment responsive than in general adult samples. One contributor to poorer treatment outcomes may be abused women’s difficulties in forming and maintaining secure relationships, as reflected in insecure attachment styles, which could also impede the development of a positive therapeutic alliance. The current study examines how attachment orientation (i.e., anxiety and avoidance) and development of the working alliance are associated with treatment outcomes among depressed women with histories of childhood sexual abuse. Method Seventy women seeking treatment in a community mental health center who had Major Depressive Disorder and a childhood sexual abuse history were randomized to Interpersonal Psychotherapy or treatment as usual. Results Greater attachment avoidance and weaker working alliance were each related to worse depression symptom outcomes; these effects were independent of the presence of comorbid Borderline Personality Disorder and Post-Traumatic Stress Disorder. The effect of avoidant attachment on outcomes was not mediated by the working alliance. Further, working alliance had a stronger effect on depression outcomes in the Interpersonal Psychotherapy group. Conclusion Understanding the influence of attachment style and the working alliance on treatment outcomes can inform efforts to improve treatments for depressed women with a history of childhood sexual abuse.

Therapeutic Alliance with Juvenile Sexual Offenders: The Effects of Trauma Symptoms and Attachment Functioning

“…Overall, the results reveal that certain types of attachments, specifically positive peer attachments and communication within the father-child relationships were associated with greater alliance and sexual abuse trauma was associated with lower alliance. Generally, these results are consistent with psychotherapy literature and research on the relationships between alliance and anxiety-related trauma (Smith et al, 2012) and attachment (Zorzella, Muller, & Classen, 2014). One meta-analysis for example revealed associations between global attachment orientations in interpersonal relationships and therapeutic alliances (Diener, Hilsenroth, & Weinberger, 2009).…”

Attachment, Self-Esteem and Subjective Well-Being Among Survivors of Childhood Sexual Trauma

“…Other studies have also found that individuals who experience childhood sexual trauma are likely to have symptoms of depression, PTSD, anxiety, dissociations (Leserman, 2005;Smith et al, 2011). A sample of women experiencing major depression and childhood sexual abuse was assessed on their social maladjustment, depression and death ideation.…”

“…Results from this study yielded those women who experience childhood sexual trauma had a high rate of suicidal behaviors. These individuals displayed higher levels of problems with social and leisure time including intimate or peer relationships (Smith et al, 2011). In addition, a review of literature found individuals who experience childhood trauma are likely to re-victimized in adulthood which also impacts overall levels of subjective well-being (Leserman, 2005).…”

“…Survivors who have experienced childhood sexual trauma, or any unwanted sexual act prior to the age of 18, are more likely to endorse a myriad of mental health symptomology than are individuals who do not have a history of childhood sexual trauma (Bailey et al, 2007). This symptomology can be consistent with psychological disorders such as PTSD, depression and Bipolar Disorder (Smith et al, 2011). In addition, to vulnerability to these mental health diagnoses, survivors of childhood sexual abuse also have a higher likelihood of revicitimization or additional similar trauma in adulthood (Royse et al, 1993).…”

Trajectory of substance use after an HIV risk reduction intervention

“…In addition, some staff routinely demonstrated many interpersonal behaviors and characteristics that have been noted in the psychotherapy literature to be important to the development of a “positive therapeutic alliance,” including reflective listening, respectful and positive regard, and paying attention to the participant’s experience (34). Such characteristics are associated with positive treatment outcomes in many vulnerable populations, including substance users (35–37), and may have had a similarly positive effect in this experimental setting as well.…”