Pilot test of a measure to assess therapeutic distance and its association with client attachment and corrective experience in therapy

Abstract

Objectives: The Therapeutic Distance Scale (TDS) was developed in this project to assesse clients' experiences of distance versus engagement with their therapist. Method: In a survey study of 47 university clients at the “mid-stage” and 34 of these clients at termination, four TDS subscales were identified: Too Close, Too Distant, Growing Autonomy, and Growing Engagement. Results: TDS subscales were correlated as expected with working alliance and Client Attachment to Therapist. As hypothesized, (i) pre-therapy attachment Avoidance was significantly correlated with perceptions of therapists as Too Close (but not Too Distant), (ii) pre-therapy Anxiety was significantly correlated with Too Distant (but not Too Close); furthermore, among clients who developed a secure attachment to their therapist, (iii) pretherapy Avoidance was significantly correlated with Growing Engagement; however, (iv) contrary to expectations, pre-therapy anxiety was not significantly associated with Growing Autonomy. Conclusions: The TDS is a promising measure for assessing the in-therapy corrective emotional experiences of clients with hyperactivating attachment (i.e. increasing autonomy) and deactivating attachment (i.e. increasing engagement).

Abstract

Objectives: The Therapeutic Distance Scale (TDS) was developed in this project to assesse clients’ experiences of distance versus engagement with their therapist. Method: In a survey study of 47 university clients at the “mid-stage” and 34 of these clients at termination, four TDS subscales were identified: Too Close, Too Distant, Growing Autonomy, and Growing Engagement. Results: TDS subscales were correlated as expected with working alliance and Client Attachment to Therapist. As hypothesized, (i) pre-therapy attachment Avoidance was significantly correlated with perceptions of therapists as Too Close (but not Too Distant), (ii) pre-therapy Anxiety was significantly correlated with Too Distant (but not Too Close); furthermore, among clients who developed a secure attachment to their therapist, (iii) pretherapy Avoidance was significantly correlated with Growing Engagement; however, (iv) contrary to expectations, pre-therapy anxiety was not significantly associated with Growing Autonomy. Conclusions: The TDS is a promising measure for assessing the intherapy corrective emotional experiences of clients with hyperactivating attachment (i.e. increasing autonomy) and deactivating attachment (i.e. increasing engagement).

Zusammenfassung:

Ziele: Die Therapeutische Entfernungsskala (Therapeutic Distance Scale, TDS) wurde im Rahmen dieses Projektes entwickelt, um die Patienten Erfahrung von Distanz vs. Beteiligung mit ihrem Therapeuten zu untersuchen. Methode: In einer Erhebungs-Studie an 47 Universitäts-Patienten, die sich im mittleren Teil der Behandlung befanden, 34 von diesen Patienten bfanden sich in der Abschlussphase der Behandlung, wurden 4 TDS-Skalen identifiziert: „zu nah“, „zu weit entfernt“, Wachsende Autonomie, Wachsende Beteiligung. Ergebnisse: TDS Subskalen waren wie erwartet korreliert mit dem Arbeitsbündnis und der Patientenbindung zum Therapeuten. Wie vorhergesagt, (i) war die prä-Therapie Bindungsvermeidung signifikant korreliert mit der Wahrnehmung der Therapeuten als „zu nah“ (aber nicht „zu weit entfernt“), (ii)prä-Therapie Angst war signifikant korreliert mit „zu weit entfernt“ (aber nicht „zu nah“); des Weitern war unter den Patienten, die eine sichere Bindung zu ihren Therapeuten aufgebaut hatten, (iii) die prä-Therapie Vermeidung signifikant assoziiert mit wachsender Beteiligung; (iv) entgegen der Erwartungen jedoch war die prä-Therapie Angst nicht signifikant assoziiert mit wachsender Autonomie. Zusammenfassung: Die TDS ist ein vielversprechendes Messinstrument für die Untersuchung der korrektiven emotionalen Erfahrungen, die innerhalb einer Therapie von Patienten mit hyperaktivierter Bindung (z.B. gesteigerter Autonomie) und deaktivierter Bindung (z.B. gesteigerter Dialog) gemacht werden.

Objetivos: A Therapeutic Distance Scale (TDS) foi desenvolvida neste projeto para avaliar as experiências de distância versus envolvimento dos clientes com o seu terapeuta. Método: Foram identificadas quatro subescalas da TDS num questionário aplicado a 47 clientes universitários em “fase intermédia” do seu curso, e a 34 em fase final: Demasiado Próximo, Demasiado Distante, Autonomia Crescente e Envolvimento Crescente. Resultados: Tal como expectável, as subescalas da TDS foram correlacionadas com a aliança terapêutica e com o Vínculo do Cliente para com o Terapeuta. Como hipotetizado, (i) a vinculação pré-terapia de tipo Evitante mostrou-se significativamente correlacionada com perceções do terapeuta como Demasiado Próximo (mas não Demasiado Distante), (ii) a Ansiedade pré-terapia apresentou-se significativamente correlacionada com a subescala Demasiado Distante (mas não Demasiado Próximo); para além disto, nos clientes que desenvolveram uma vinculação segura com o terapeuta, (iii) a vinculação pré-terapia de tipo Evitante foi significativamente correlacionada com o Envolvimento Crescente; no entanto, (iv) contrariamente ao expectável, a Ansiedade pré-terapia não se mostrou significativamente correlacionada com a Autonomia Crescente. Conclusões: A TDS é uma medida promissora para avaliar as experiências emocionais corretivas em terapia de clientes com vinculação hiperativada (i.e., autonomia crescente) e vinculação desativada (i.e., envolvimento crescente).

本計畫旨在發展能夠評估當事人對於治療者有距離感或是願意投入治療關係的測量工具TDS。方法：以問卷調查的方式探討47位處於治療中期，以及34位處於治療結束階段的大學生當事人。。TDS共分成四個分量表：太靠近、太疏遠、漸趨自主性、以及漸趨投入。結果：如所預期的，各分量表均與工作同盟以及當事人對治療者之依附有相關。就如研究假設（i）在治療前有逃避依附者會認為與治療者太靠近（而非太疏遠），（ii）在治療前有焦慮者會認為與治療者太有距離（而非太靠近）相關；此外，其中有部分當事人逐漸發展出對治療者的安全依附，（iii）在治療前有逃避依附者和漸趨投入有相關；然而，（iv）與研究假設相反的，治療前之焦慮與漸趨自主性並無顯著相關。結論：TDS是一項前景可期的測驗，可以用來測量在治療中過度依附(例如逐漸增加自主性)以及逐漸減少依附(例如逐漸增加投入)當事人之矯正性情緒經驗。

Keywords:

• client attachment to therapist
• therapeutic distance
• corrective emotional experience
• working alliance
• interpersonal therapy

Supplemental data

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Notes

1. Ideally the 36-item pool should be examined with exploratory factor analysis (EFA) followed by confirmatory factor analysis (CFA). Experts in instrument development (c.f. Worthington & Whittaker, 2006) suggest a minimum of five subjects per item for EFA, and a separate minimum sample of 200 subjects for CFA. Unfortunately, our present resources allow collection of data from only 50–70 clients per year. Assembling the required sample for EFA of 180 clients would require 2–3 years, with 3–4 more years for CFA. Thus, practical constraints required us to use an approach based on item-total correlations and internal reliability.