Adult attachment as a predictor and moderator of psychotherapy outcome: A meta-analysis

J Clin Psychol. 2018 Nov;74(11):1996-2013. doi: 10.1002/jclp.22685. Epub 2018 Sep 21.


Bowlby's attachment theory describes characteristic patterns of relating to close others and has important implications for psychotherapy. Attachment patterns have been characterized as secure (healthy interdependence with others), anxious (overdependence on others), and avoidant (difficulty relying on others). We update a previous meta-analysis to determine the association of patient attachment with psychotherapy outcome. Meta-analysis of 36 studies (3,158 patients) suggested that patients with secure attachment pretreatment show better psychotherapy outcome than insecurely attached patients. Further, improvements in attachment security during therapy may coincide with better treatment outcome. Finally, preliminary moderator analyses suggest that those who experience low pretreatment attachment security may find better treatment outcome in therapy that incorporates a focus on interpersonal interactions and close relationships. The article closes with research limitations, diversity considerations, and therapeutic practices.

Keywords: attachment style; meta-analysis; psychotherapy outcome; psychotherapy relationship.

Publication types

  • Case Reports
  • Meta-Analysis
  • Review

MeSH terms

  • Adult
  • Anxiety
  • Female
  • Humans
  • Interpersonal Relations
  • Male
  • Object Attachment*
  • Outcome and Process Assessment, Health Care*
  • Professional-Patient Relations
  • Psychotherapy*
  • Reactive Attachment Disorder / psychology
  • Reactive Attachment Disorder / therapy
  • Treatment Outcome