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TMatch: Matching Clients to Therapists
Based on Client Attachment Style

Short Restatement of Matching Recommendations

Attachment theory discusses individual's manners of relating to others in terms of the attachment styles of secure (sometimes called autonomous), avoidant (sometimes called dismissing), or ambivalent (sometimes called preoccupied).There are several matching recommendations, all of which are based on the extent to which clients are avoidant or ambivalent.

  1. Avoidant clients should be matched with an attuned, following, warm, flexible "holding" type of therapy; ambivalent clients should be matched with firm, consistent therapy with clear boundaries.
  2. Avoidant clients should be matched with therapy that gets them more in touch with their emotions, and with therapists who emphasize connecting emotionally with clients; ambivalent clients should be matched to therapy with more structure.
  3. Avoidant clients should be matched with longer term therapy; ambivalent clients should be matched with shorter term therapy.

Client Assessments

Assessment of adult attachment styles is a complex and controversial subject. For very complex reasons, which are explained in part on the page showing the assessment (see link below), the assessment for the first versions of TMatch was based on the Relationship Questionnaire (RQ) (Bartholomew & Horowitz, 1991). This questionnaire has four descriptions, which TMatch asked clients to put into the order in which they best described themselves. Clients were then asked to rate each of these styles as to how much it applied to them. After some manipulation, this produced a score for avoidant versus ambivalent, since all the recommendations were in those terms.

Therapist Assessment, Matching Recommendation 1

The first assessment used the exact language of the first recommendation.

Therapist Assessment, Matching Recommendation 2

The degree to which therapists emphasize clients getting in touch with their emotions, the degree to which they emphasize connecting emotionally with clients, and the amount of structure in therapy, were assessed with four questions and the rating of one of the "help-ways" in the TMatch section that asked therapists to order 7 different ways of helping clients.

  1. The help-way an opportunity for deep experiencing and increased awareness of feelings and sensations.
  2. To what degree is what happens during your therapy planned?
  3. To what degree is your usual method of therapy structured?
  4. What level of intimacy usually occurs during your therapy?
  5. What is the general level of emotional intensity during your therapy sessions?

Therapist Assessment, Long-Term Emphasis of Therapy

The assessment for long-term emphasis of therapy was made with a combination of two questions relating to therapy complexity, one question directly related to therapy depth, and a section of direct questions asking therapist about their preference for length of therapy. The questions about complexity were added because it was assumed that complex therapy would require more time.


Future Use of Attachment Style for Client-Therapist Matching

Results of Study: Client Assessment

Based on their answers to the statements from Relationship Questionnaire by Bartholomew and Horowitz (1991), using a complex formula, clients were placed on a scale of Avoidance versus Ambivalence of +15 to -15. On this scale, for all clients and pilot testers, the mean was 1.00 with sd = 2.70. With such a small standard deviation, there was not as much useful information produced by this assessment as had been hoped. Another problem is that there are different systems for categorizing attachment styles, with different numbers of dimensions and different names for the styles. The systems of categorizing on which the matching recommendations in the literature are based do not necessarily match the most current categorization systems.

Results of Study: Therapist Assessment of Matching Recommendation 1

Therapists were assessed as to whether their therapist tended to be "warm, attuned, flexible, and empathetic" vs. "firm and consistent, with clear boundaries." Almost all therapists answered strongly in the direction of being warm and attuned. It is probably true that almost all therapists do see themselves as warm, attuned, flexible, and empathetic. However, therapists probably have more differences in how firm they are, and how concerned about clear boundaries. These therapy aspects do not seem to be opposites. With these problems in interpretation of the meaning of this question, and with so little differentiation among therapists on this assessment, this was not a useful assessment, and thus not a useful matching recommendation.

Results of Study: Therapist Assessment of Matching Recommendation 2

The assessment of therapists tendency to get clients more in touch with their emotions worked only marginally well. There was a tendency for therapists to answer questions in the section in very similar ways, in that almost all therapists thought there were high levels of emotional intensity and intimacy in their therapies. There were also some problems in assessing therapists' usual amounts of structure in therapy, due to some confusion and inexactness of the meaning of the concept of "structure."

Results of Study: Therapist Assessment of Matching Recommendation 3

The assessment of emphasis on longer or shorter terms for therapy was fairly successful.

Results of Study: Matching Success

This matching criterion was not successful. The client assessments of attachment styles did not work well. The therapist assessments also in general did not work well. In addition, the matching recommendations in the literature, which were mostly for different treatments for different attachment styles, and did not translate well into matching different therapists to different client attachment styles.

Future Success of Matching Using Attachment Style

Matching by attachment style still has some potential. Since the style of assessment now seems to be in terms of avoidance and anxiety, the main condition for trying this criterion again would be matching suggestions using these same dimensions. In addition, an instrument short enough to fit on one page of the client questionnaire would be needed. Attachment theory is an extremely complex and rich field, which is constantly undergoing changes, especially in the area of adult attachment, which is relatively new. Perhaps in the future the client assessment problems will be solved, and this criterion could be tried again.

Relevance of Work by Brent Mallinckrodt

Some relevant research on attachment style has been done recently by Brent Mallinckrodt and his associates, of which I was not aware when the first version of TMatch was created. Mallinckrodt et al. studied clients' attachment styles with therapists with a special instrument they developed. The significance of this for matching is that until this work, attachment styles in adults were primarily studied in the context or romantic relationships, and certainly not in the context of therapeutic relationships. It would be wonderful if this work by Mallinckrodt could be directly used in client-therapist matching, but isn't quite that directly relevant yet. For matching by this criterion, what is needed is a set of matching recommendations for different therapist qualities based on different client attachment styles. Mallinckrodt does recommend different treatment strategies for different client attachment styles, but these are complex treatment strategies, and not translateable into different therapist qualities. Hopefully in the future there will be a useful matching system for attachment styles that comes out of work by Mallinckrodt and associates, or possibly other researchers, but until then, this area of matching should probably not be included in TMatch.


For more information, or to give feedback, email Kenneth Frankel, Ph.D.

References

Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61, 226-244.

Holmes, J. (1997). Too early, too late: Endings in psychotherapy - an attachment perspective. British Journal of Psychotherapy, 14(2), 159-171.

Mallinckrodt, B., Gantt, D. L., & Coble, H. M. (1995). Attachment patterns in psychotherapy relationship: Development of the client attachment to therapist scale. Journal of Counseling Psychology, 42(3), 307-317.

Slade, A. (1999). Attachment theory and research: Implications for the theory and practice of individual psychotherapy with adults. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 575-594). New York: Guilford Press.