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 the treatments for depressed women with a history of childhood sexual abuse.

© 2012 Wiley Periodicals, Inc.

Figures

Figure 1. The Moderation of the Relationship between Working Alliance Overall Score and BDI Scores by Treatment Type

Note: Only the interaction between the overall WAI score and treatment condition is shown. The interactions between each of the WAI scales (Therapeutic Bond, Agreement on the Tasks, and Goals of Therapy) and treatment condition as it relates to changes in BDI scores over time were similar to that depicted here. Tests of the simple slopes indicated that that there was a significant downward slope for the IPT condition (χ2(1)=6.94, p<.01). The simple slope of TAU was not significant (χ2(1)=1.81, p>.05).