Attachment and alliance in the treatment of depressed, sexually abused women.
BACKGROUND
Depression among women with sexual abuse histories is less treatment responsive than in general adult samples. One contributor to poorer treatment outcomes may be abused women's difficulties in forming and maintaining secure relationships, as reflected in insecure attachment styles, which could also impede the development of a positive therapeutic alliance. The current study examines how attachment orientation (i.e. anxiety and avoidance) and development of the working alliance are associated with treatment outcomes among depressed women with histories of childhood sexual abuse.


METHOD
Seventy women seeking treatment in a community mental health center who had Major Depressive Disorder and a childhood sexual abuse history were randomized to Interpersonal Psychotherapy or treatment as usual.


RESULTS
Greater attachment avoidance and weaker working alliance were each related to worse depression symptom outcomes; these effects were independent of the presence of comorbid Borderline Personality Disorder and Post-Traumatic Stress Disorder. The effect of avoidant attachment on outcomes was not mediated by the working alliance. Further, working alliance had a stronger effect on depression outcomes in the Interpersonal Psychotherapy group.


CONCLUSION
Understanding the influence of attachment style and the working alliance on treatment outcomes can inform efforts to improve the treatments for depressed women with a history of childhood sexual abuse.