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Attachment Style and Response to Psychotherapy for Depression

Patients with avoidant attachment might find CBT more to their liking.

An important question for psychotherapists is how to determine the preferred treatment for an individual depressed patient. Interpersonal psychotherapy (IPT) and cognitive-behavioral therapy (CBT) are similarly effective treatments for depression, but they have important differences. IPT posits a bidirectional relationship between interpersonal problems and depressive symptoms; it focuses on changing the patient’s experience of her interpersonal world. CBT posits a bidirectional relationship between dysfunctional thoughts and depressive symptoms; it focuses on changing dysfunctional thoughts.

These researchers hypothesized that IPT is better suited to individuals with anxious attachment (i.e., valuing relationships over autonomy and experiencing heightened sensitivity to rejection) and that CBT is better suited to individuals with avoidant attachment (i.e., denying the importance of relationships and valuing rationality over emotions). The researchers conducted a randomized, controlled trial in which 56 patients with major depression received CBT or IPT and completed self-report scales on attachment style.

CBT and IPT performed equally well in improving depression symptoms. In analyses conducted on intent-to-treat and completer groups, avoidant attachment predicted better response to CBT than to IPT on all outcome measures, but anxious attachment did not predict different outcomes with the two treatments. The findings for CBT remained consistent even after adjustment for obsessive-compulsive and avoidant personality disorder symptoms.

Comment: Although the study number is small and attachment style is a small contributor to depression outcomes, the findings are consistent across the study analyses. It makes sense that individuals who overvalue rationality and deny the importance of relationships would prefer a tightly reasoned intrapersonal therapy to a more emotion-focused, interpersonal one. Attachment-style questionnaires are simple to administer. Identifying avoidant attachment can help psychotherapists individualize treatment.

— M. Katherine Shear, MD

Dr. Shear is Marion E. Kenworthy Professor of Psychiatry, Columbia University School of Social Work, in New York City.

Published in Journal Watch Psychiatry February 12, 2007

Citation(s):

McBride C et al. Attachment as moderator of treatment outcome in major depression: A randomized control trial of interpersonal psychotherapy versus cognitive behavior therapy. J Consult Clin Psychol 2006 Dec; 74:1041-54.

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