Attachment style and depression: an investigation into interpersonal factors and processes
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Introduction: Depression is one of the most dominant universal mental health disorders and has a high rate of persistency and recurrence. Interpersonal theories posit that it is interpersonal, or relational, factors that serve to cause and maintain depression, which is supported by a growing evidence base. CBASP is an interpersonally-focused psychotherapy specifically designed for the treatment of chronic depression and employs a variety of cognitive, behavioural and interpersonal techniques within the therapeutic relationship to help individuals evaluate their interpersonal exchanges and consider the implications. Research has highlighted the effectiveness of CBASP for this client group, however there is limited research investigating therapist and client factors that contribute to positive outcomes. Attachment style and mentalization are two such factors that are theoretically and empirically linked to an individual’s way of relating to others but have not been investigated in relation to outcomes in CBASP. Aims: A systematic review aimed to identify and evaluate significant social and interpersonal mediators that account for the relationship between attachment style and depressive symptoms. An empirical study then explored the role of therapist and client attachment style, mentalisation, and therapeutic alliance on clinical outcomes in CBASP. Methods: A systematic search of the literature exploring social and interpersonal mediators between attachment style and depressive symptoms was conducted in order to identify and evaluate mediators. The empirical study used a longitudinal case series design where both therapist and client attachment style, mentalization and the therapeutic alliance were assessed, and clinical outcomes were measured at each session to allow evaluation of change over time. Results: The systematic review provided evidence that specific social and interpersonal variables mediate the relationship between attachment and depressive symptoms, specifically social support, social anxiety, social self-efficacy, relationship satisfaction, interpersonal negative events, and interpersonal dependency. Two studies failed to find mediating effects of social support and social self-efficacy. The findings of this review are interpreted with caution as there contained several methodological limitations that affect the ability to generalize to other populations and infer causation. Findings from the empirical study provided evidence for the role of therapist attachment style and mentalization in relation to the therapeutic alliance and clinical outcomes in chronic depression in CBASP. Client attachment style and mentalization were not found to have a significant impact on the process of change but did account for some variance in symptoms of depression. Findings should be cautioned due to the small sample size and lack of statistical power to detect smaller effects. Discussion: The findings of this thesis suggests that there exist social and interpersonal factors that mediate the relationship between attachment style and depressive symptoms, and this has clear socio-political and clinical implications. However more research using robust methods of design and statistical analysis are needed in order to provide clarity in this field. The empirical study provided rich and novel data that suggests that therapist attachment style and mentalization, more so than client factors, are important in developing the therapeutic alliance and promoting symptom reduction over the course of treatment. Further research utilizing a larger sample size could provide more robust evidence for this association.