AAI patients' attachment classification predicts their in-session interpersonal behavior: from attachment to transference

Topic: So far, studies that have investigated how patients’ attachment patterns manifest in psychotherapy have yielded limited results, and the implications of treating patients with different attachment patterns remain relatively unexplored. For this reason, many psychotherapists and psychoanalysts believe, to cite Morris Eagle, that attachment categories “cut to broad a swath”. Aim: The aim of this study was to compare the in-session discourse of patients with secure, dismissing and preoccupied attachment states of mind on the Adult Attachment Interview (AAI) by analyzing the interpersonal function implicit in patients’ discourse rather than the form or content of the patients’ narratives. Method: 4 independent raters applied the Patient Attachment Coding System (PACS) to session transcripts of 46 patients, each of whom had been independently assessed with the AAI. Results: Secure, dismissing and preoccupied patients’ discourse was found to differ significantly when assessed with PACS, in ways that are both consistent with the predictions of attachment theory and clinically significant. For instance, secure patients are able to express distress, ask for and accept help. Conversely, insecure patients, fearful of becoming too close or too distant from the therapist, adopt discursive strategies that work outside of awareness to manipulate the therapeutic relationship and maintain a tolerable emotional proximity to the therapist (e.g. downplaying their suffering, or resisting the therapist’s support). Discussion: While these results need replication, this study shows that the different attachment patterns have distinctive and meaningful manifestations in the psychotherapy process.