Current Literature to Clinical Practice

Empirical Research on Attachment in Group Psychotherapy: Moving the Field Forward
Marmarosh, Cheri L.
PSYCHOTHERAPY; MAR 2014, 51 1, p88-p92, 5p.
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group therapy
group process and outcome
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Empirical Research on Attachment in Group Psychotherapy: Moving the Field Forward / COMMENTARY
Attachment Styles and Curative Factors
Attachments to the Group: Do They Facilitate Secure Personal Attachments?
Changing Attachments: Are We Helping Group Members Become More Secure?
Limitations of Research
Clinical Implications: Applying Attachment Theory in Group Therapy
Full Text
By: Cheri L. Marmarosh
The George Washington University;

It is striking how few articles have applied attachment theory to group psychotherapy, given the expansive literature, both clinical and empirical, that has emphasized the link between attachment theory and psychotherapy. Several books have been written applying attachment theory to the clinical treatment of individuals (Wallin, 2007; Holmes, 1996; Flores, 2004; Fonagy, 2001), couples (Johnson & Whiffen, 2003), and families (Erdman & Caffery, 2003; Hughes, 2007). It is surprising how attachment styles/dimensions, which have been shown to influence a wide range of interpersonal functioning (Mikulincer & Shaver, 2007), psychotherapy treatment (Diener & Monroe, 2011), and group dynamics (Smith, Murphy, & Coats, 1999), have not received more attention from group therapy researchers.

The lack of research applying attachment theory to group therapy makes these three studies, and George Tasca’s work over the past 10 years, incredibly important to the field of group therapy. Tasca’s research program has contributed some of the most important findings with regard to how group members differently respond to the group. It is all too easy for us to assume that all group members will respond to the demands of intimacy, conflict, and emotion regulation in the same way and that all group treatments facilitate the same change processes for members. Tasca and colleagues’ (Tasca, Taylor, Bissada, Ritchie, & Balfour, 2004; Tasca et al., 2006, 2009; Tasca, Balfour, Ritchie, & Bissada, 2007a, 2007b) research reminds us that individual differences such as attachments influence the way the group, the members, and the leaders are experienced and perceived by the individual from the moment the group begins.

Attachment Styles and Curative Factors

The link between attachment styles/dimensions and the group process is one of the most relevant findings for clinicians who practice group therapy. Group therapists often struggle with interventions that seem to facilitate more depth and cohesion for some members while simultaneously excluding members or activating a fight-or-flight defense in others. Many group therapists have written about their recommendations for fostering group cohesion (Burlingame, Fuhriman, & Johnson, 2001; Yalom & Leszcz, 2005), and most fail to address how attachment styles influence the development of cohesion and the very experience of being a member in a cohesive group.

Tasca et al.’s (2006) findings show us that more anxious group members, those preoccupied with fears of being abandoned, do better in group treatments that foster cohesion, are more relational, and focus on emotion regulation, compared with more structured groups. However, their research findings also demonstrate that this is not the case for all group members. Those with greater attachment avoidance, those who tend to withdraw from relationships, have greater rates of dropping out of group therapy (Tasca et al., 2006; Tasca, Taylor, Bissada, Ritchie, & Balfour, 2004) and are repelled by the pressures to be more intimate in the group (Illing, Tasca, Balfour, & Bissada, 2011; Tasca et al., 2007b). Unlike more anxious group members, more avoidant group members tend to feel uncomfortable with the pull to be more cohesive.

Just as group cohesion is experienced differently by those who are more anxious or more avoidant, Gallagher et al. (2014, pp. 66–77) reveal that interpersonal learning, like group cohesion, is associated with positive outcomes for those with greater attachment anxiety but not avoidance. This is important, given those with more attachment anxiety tend to perceive the group climate as being more avoidant and having more conflict (Harel, Shechtman, & Cutrona, 2011). Despite the conflict, more anxious members appear to benefit from the group process where the relationships are the focus and interpersonal learning is placed at the center of the treatment.

Shechtman and Dvir (2006) studied the transcripts of preadolescent counseling group sessions (2nd, 6th, and 10th) and found that more anxious group members benefited from disclosure in group therapy but not as much as those who were more secure. This difference was even more pronounced with those who were more avoidant. The more avoidant members “had the lowest rates of self-disclosure, did the least effective work, and were most negative to others” (Shechtman & Dvir, 2006, p. 38). These findings support Tasca’s (2014, pp. 53–56) points in this special section that we need to continue to study how attachments influence the actual group process of exploration during the session, the ability of members to be empathic with each other, and the processing of ruptures and repairs. Focusing on the actual process that unfolds within the sessions is critical to future studies, especially given the negative relationship between attachment insecurity and forgiveness (Mikulincer, Shaver, & Slav, 2006), effective caregiving (Westmaas & Silver, 2001), and empathy (Wayment, 2006; Rubino, Barker, Roth, & Fearon, 2000).

Attachments to the Group: Do They Facilitate Secure Personal Attachments?

Social psychologists have long argued the significance of attachments to groups (Smith et al., 1999), yet only a few group therapists have applied the concept of group attachment or group identity to group therapy (Marmarosh, 2009; Marmarosh & Markin, 2007; Markin & Marmarosh, 2010). The article by Keating, Tasca, Gick, Ritchie, Balfour, and Bissada (2014, pp. 78–87) encourages us to continue to study group attachments. Their findings indicate that attachment anxiety and avoidance regarding the therapy group do improve during the life of the group. More importantly, this improvement generalizes to more secure individual attachment up to 1 year after group therapy. These are impressive findings and shed light on the interactive nature of our dual identities and how enhancing one’s attachment to the group relates to increased security in adult relationships outside the group. This is an area ripe for future research. Although we have evidence that the attachment to the therapy group relates to more secure dyadic attachments after treatment, we do not know whether this also relates to positive changes in future group attachments that develop after the group ends.

Changing Attachments: Are We Helping Group Members Become More Secure?

There are relatively few studies, even in individual psychotherapy, that address how therapy treatment facilitates changes in attachment and how these changes relate to symptoms and interpersonal functioning at the end of treatment (Fonagy et al., 1996; Kilmann et al., 1999; Levy et al., 2006; Kinley & Rayno, 2013; Travis, Binder, Bliwise, & Horne-Moyer, 2001). The article by Maxwell, Tasca, Ritchie, Balfour, and Bissada (2014, pp. 57–65) in this edition, supports the few previous studies that have found positive changes in attachment related to group therapy (Kilmann et al., 1999; Kinley & Rayno, 2013; Kirchmann et al., 2012; Tasca et al., 2007a). Impressively, the researchers reveal that change in self-reported individual attachment is evidenced 1 year after treatment ends, and is associated with improvement in interpersonal problems and symptoms of depression. More specifically, they found that both dimensions of attachment anxiety and avoidance are reduced with reduction of attachment anxiety related to decreased depressive symptoms and reduction of attachment avoidance related to decreased interpersonal problems over time. In essence, more avoidant group members, those who struggle with interpersonal learning and the pressure to be more intimate in the group, benefitted from the group with regard to their interpersonal problems decreasing. The very issue that was a challenge for them in the group was also what appeared to have changed significantly over time.

These findings support the earlier empirical work of Kilmann et al. (1999), who also found that attachment-based group therapy promoted changes in interpersonal functioning and more secure attachments. Interestingly, they also found that people with the fearful–avoidant (high anxiety and high avoidance) pattern showed the greatest positive changes after treatment. Again, those members who might struggle the most in the group owing to fears of being rejected and the use of withdrawal to cope, benefitted significantly from participating in the group treatment.

Kirchmann et al. (2012), similar to Kilmann et al. (1999), focused on attachment categories instead of dimensions (anxiety and avoidance) and found that one of five patients moved from an insecure to secure attachment category at the end of treatment, and they found even more improvement 1 year after the end of group treatment. Much more research is needed to understand what processes within the group lead to more secure attachments dimensionally and categorically. In addition, it is important to keep linking these changes in attachment to changes in symptoms and interpersonal functioning years after group treatment ends. An interesting study in couple psychotherapy found significant differences in treatment outcome 4 years after treatment that was not detected at termination, indicating the importance of long-term follow-up (Snyder, Wills, & Grady-Fletcher, 1991). In addition to extended follow-up, it is important to study what processes in the sessions influence these changes. Snyder et al. (1991) found that couples who received insight-oriented treatment had less rates of divorce 4 years later compared with those who did not receive insight-oriented treatment. If we apply this to group therapy, we could wonder how much emotional and cognitive insight is necessary for change in group therapy. Do group members need to gain insight into their attachment style/patterns in the group? Do group members need to learn the origins of their current attachment styles? Can group members internalize new mental representations based on their emotional experiences alone in the group sessions, or does long-lasting change require all these levels of insight? The answer may be different for those members with different attachment styles.

Limitations of Research

Despite my praise of these three outstanding articles and Tasca’s work, there are limitations to what we currently know about attachment and group therapy. One of the biggest limitations of their research is the treatment mainly focuses on women with eating disorders. We can assume the findings will generalize to men and other populations, but we need empirical research to support this assumption. There are studies supporting these findings using different patient populations. For example, Flores (2004) has described how attachment styles relate to group members with addictions; Shechtman and Dvir (2006) have studied attachment in preadolescent groups in the school system; Kirchmann et al. (2012) studied inpatient group members; and Kivlighan, Lo Coco, and Gurro (2012) studied Italian graduate students engaged in groups as part of a course in their counseling program. Despite the diversity of samples, the majority of studies still have greater female participants compared with males, who are often the minority in these studies.

In addition to replicating the studies with diverse populations and group therapy interventions, the researchers in these studies rely mainly on individual self-report assessments and do not delve further into the collective experience of the group. Group researchers (Forsyth, 2000; Kivlighan et al., 2012) have reminded us repeatedly that we often emphasize the individual member’s perceptions as opposed to the collective group’s observation, even when we consider the nested nature of the group. Kivlighan et al. (2012) argue that one must also take into account the attachment styles of other members that make up the group if we are to truly understand how attachment styles relate to group process. They used actor–partner interdependence modeling to examine the relationships among group members’ individual attachments and perceptions of the group’s climate while also considering the aggregated attachment patterns of the group members’ combined perceptions of the group climate and attachment. In essence, they not only focused on how individual group members’ attachments influence the perceptions of the group, but they also took into account how the attachment styles of the other group members influenced these relationships. When doing this, they found contradictory findings to previous studies that only considered the individual member’s attachment and perceptions of the group (Harel et al., 2011; Illing et al., 2011). Future studies are needed that take into account how the make-up of the group, the multiple interacting attachment styles, influences the group process, group cohesion, group climate, and ultimately change.

A final limitation is similar to neglecting the impact of the group members’ attachment styles and is the lack of attention to the group leaders’ attachments. Social psychologists have emphasized the importance of the group leader and have empirically studied the influence of the leaders’ attachment styles on group members in the military (Davidovitz, Mikulincer, Shaver, Izsak, & Popper, 2007). Specifically, they found that leader anxiety was related to more self-serving motives, poor leadership, and poor follower functioning in certain situations. Leader attachment avoidance, in contrast, was related to a failure to be a secure base for group members and led to members’ poor socioemotional functioning and mental health. They found that more avoidant leaders had the worst impact on insecure group members, but they also eroded the well-being of secure members over time despite the buffering effect of their secure attachment (Mikulincer & Shaver, 2007). Given the powerful impact that the leaders’ attachment had on military groups in these studies, one can imagine the impact that leader attachment has on more vulnerable group members who come to the therapy group seeking a secure base. Empirical studies are needed to explore how therapy leader attachments influence coleadership, group climate, emotion regulation, conflict resolution, cohesiveness, disclosure, termination, and treatment outcome. Similar to the attachment research within individual therapy, research is needed to explore the interaction between the leader and member attachment styles. Tasca and colleagues’ research, including the three articles in this special section, clearly demonstrates the benefit to applying attachment theory to group therapy, and more importantly, the need for future research. There is much we still have to learn.

Clinical Implications: Applying Attachment Theory in Group Therapy

Despite the limitations of the research and the need for future studies, we know for certain that attachment styles/dimensions influence group psychotherapy. Tasca, Ritchie, and Balfour (2011) have highlighted how their research findings apply to group treatment for eating disorders. They argue that therapists working with group members who have more attachment anxiety should consider interventions that facilitate the management of emotions, link emotions to eating behavior, and help members develop strategies to downregulate affect. For example, when a more anxious group member becomes flooded with fears of rejection, the group leader may stop the member to help them reflect on what happened in the session. Rather than getting carried away in a flood of emotions, the leader may help the member begin to observe himself and explore how his emotions were immediately activated in the session and, more importantly, how the intensity of his emotions may interfere with his desire for closeness in the group and relate to eating behaviors. Fosha (2000) describes more anxious patients as those who feel but cannot deal, and interventions that facilitate emotion regulation, reflective functioning, and coherence of mind are critical parts of their treatment (Wallin, 2007).

Unlike group members who feel but cannot deal, more avoidant members deal but cannot feel. They tend to engage in deactivating strategies and turn off dependency needs to sustain their sense of self-sufficiency (Wallin, 2007). In these cases, Tasca et al. (2011) argue that the group leader may want to facilitate emotional expression in the group session to gradually help the individual become less detached from his or her emotional experience. The leader may note inconsistencies or slowly help the individual share personal narratives that may facilitate the expression of more emotions. Tasca et al. (2011) highlight how the leader may first identify affect, then empathize with affect, confront defenses against affect, and later link affect and interpersonal process. Although these recommendations were made for those with eating disorders in group therapy, they can be applied to any patient in group therapy, including those with more secure attachments.

Flores (2010) argues that group therapy fosters more secure attachments by the way the group process elicits powerful emotions and over time influences brain plasticity. He describes factors that group therapists should pay attention to when promoting secure attachments and the brain changes that follow. The first is creating a group setting that maintains an optimal amount of emotional arousal similar to Tasca et al.’s (2011) description of downregulating and upregulating affect. In addition to optimal arousal, it is important for the group to emphasize implicit processes, such as changes that occur based on the experience in the relationship that may be nonverbal or out of awareness. These changes create new neurological pathways that alter procedural memory and implicit rules about people and relationships. Flores (2010) eloquently states, “From a psychobiological standpoint, group psychotherapy can be thought of as a delicate establishment of a regulatory attachment relationship aimed at stabilizing physiology and emotions, and revising the emotional memory of attachment patterns.” (p. 559).

Based on the work of Tasca et al. (2011), Flores (2004, 2010), and many others (Bowlby, 1988; Wallin, 2007; Fonagy, 1996; Jurist & Mehan, 2008; Mikulincer & Shaver, 2007), Marmarosh, Markin, and Spiegel (2013) developed the first book describing how attachment theory can be applied to any psychotherapy group and includes ways in which attachments influence the selection of group members, the group intakes, the development of cohesion, the processes of change, and termination. Much of this work was based on Tasca’s research and clinical findings over the years. He and his colleagues, including the authors of these three articles in this edition, have facilitated tremendous growth in the field, both in the practice of group therapy and the empirical study of group process and outcome.

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Submitted: February 14, 2013 Accepted: February 15, 2013

This publication is protected by US and international copyright laws and its content may not be copied without the copyright holders express written permission except for the print or download capabilities of the retrieval software used for access. This content is intended solely for the use of the individual user.

Source: Psychotherapy. Vol. 51. (1), Mar, 2014 pp. 88-92)
Accession Number: 2013-33241-001
Digital Object Identifier: 10.1037/a0032523

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