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Attachment in psychotherapy: Psychometric properties

of the Psychological Treatment Inventory Attachment
Styles Scale (PTI-ASS).

Article  in  Journal of Psychotherapy Integration · December 2011

DOI: 10.1037/a0025461

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Attachment in Psychotherapy: Psychometric
Properties of the Psychological Treatment
Inventory Attachment Styles Scale (PTI-ASS)
Marco Giannini and Alessio Gori
University of Florence and School of Comparative Psychotherapy

Elena De Sanctis
School of Comparative Psychotherapy

David Schuldberg
The University of Montana

Considering attachment as a principal that can link the main psychotherapy

models, this study describes the creation of a new measure of Attachment in
accordance both with Bowlby’s original theories and with recent advances in
psychotherapy integration. This study aims to explain the theoretical princi-
ples underlying the Psychological Treatment Inventory (PTI; Gori, Gian-
nini, & Schuldberg, 2008) and to verify the psychometrics properties (di-
mensional structure, validity, reliability) of the PTI Attachment Styles Scale
(ASS). The sample was composed of 566 persons divided into two groups:
1) Nonclinical sample (521 subjects), and 2) Clinical sample (45 subjects).
All participants completed the PTI Attachment Styles Scale; to verify some
aspects of concurrent validity, a portion of the nonclinical sample (Group 1)
completed the Italian version of the Experience in Close Relationship Ques-
tionnaire (ECR) and the Italian version of the Attachment Style Question-
naire (ASQ). Exploratory Factor Analysis (EFA) and Confirmatory Factor
Analysis were used to verify the factor structure of the instrument. Internal
consistency was verified using Cronbach’s alpha. Some aspects of concurrent
validity were verified using Pearson’s r coefficents, correlating Attachment
Scale factors with ECR and ASQ factors. Discriminant ability was assessed
using t tests comparing the clinical group and the nonclinical groups’ scores.

Marco Giannini and Alessio Gori, Department of Psychology, University of Florence

and School of Comparative Psychotherapy, Florence, Italy; Elena De Sanctis, School of
Comparative Psychotherapy; David Schuldberg, Department of Psychology, The University
of Montana.
Correspondence concerning this article should be addressed to Alessio Gori, Depart-
ment of Psychology, University of Florence, via di San Salvi, 12 – Complesso di San Salvi
Padiglione 26, 50135 Florence, Italy. E-mail: alessio_gori@libero.it

363
Journal of Psychotherapy Integration © 2011 American Psychological Association
2011, Vol. 21, No. 4, 363–381 1053-0479/11/$12.00 DOI: 10.1037/a0025461
364 Giannini, Gori, De Sanctis, and Schuldberg

Exploratory Factor Analysis (EFA) showed a structure with four factors.

Results were confirmed by Confirmatory Factor Analysis (CFA) (NNFI ⫽
.97; CFI ⫽ .97; RMSEA ⫽ .07). PTI Attachment Styles Scale (ASS) showed
good internal consistency (Secure, ␣ ⫽ .80; Preoccupied, ␣ ⫽ .81; Avoidant,
␣ ⫽ .75; Unresolved, ␣ ⫽ .80). Correlation between the PTI Attachment
Styles Scale (ASS), the ECR, and the ASQ scales was statistically significant.
Attachment theory provides an empirically grounded framework for under-
standing important aspects of interpersonal functioning in children as well as
adults. Recently, attachment theory has found increasing use within the field
of individual psychotherapy with adults and this new measure can be useful
for both research and practice.
Keywords: attachment, psychotherapy, assessment, treatment outcomes, psychological
testing

Attachment theory (Bowlby, 1969, 1973, 1980) derives from the fun-
damental premise that children have a biologically based, survival-
promoting desire from proximity to caregivers. This desire is useful for
guaranteeing to the human infant three types of support: 1) maintaining
proximity to caregivers during daily interactions; 2) offering a safe basis
from which child could leave to explore world; 3) functioning as a “safe
haven,” where the child can seek refuge in case of danger.
On the strength of ongoing interactions with their caregivers, infants
develop internal working models of attachment relationships, patterns of
expectation about interpersonal relations that include images of the self as
lovable or not, and images of the attachment figure as available or unavail-
able to meet child’s needs (Holmes, 2001). Children use these working
models to forecast the caregiver’s availability and responsiveness and to
develop behavioral strategies that are utilized to maximize closeness to the
mother or other important people.
Internal working models of attachment (Bowlby, 1980; Bretherton,
1985; Collins & Read, 1994) are thought to guide expectations about
relationships throughout life. Empirical work supports the theory that
adults exhibit a limited number of primary attachment strategies (Feeney
& Noller, 1990; Hazan & Shaver, 1987). Bowlby (1988) speculated that
generalized expectations about others and self, beliefs that form working
models in early attachment experience, may profoundly influence the
therapeutic relationship, which shares important similarities to caregiver-
infant attachment. The therapist could be conceptualized as an attachment
figure (Farber, Lippert, & Nevas, 1995), and he or she serves as a secure
base for the patient, from which the latter can more safely engage in
self-exploration (Bowlby, 1988). Indeed there is empirical evidence regard-
ing how patients in psychotherapy view their therapist as an attachment
figure (e.g., Mallinckrodt, Gantt, & Cable, 1995; Parish & Eagle, 2003)
Pspychometric Properties of the PTI-ASS 365

and about how the particular components of attachment can be differ-

ent from patient to patient (Parish & Eagle, 2003).
Besides, change in attachment classification is an outcome-goal of
therapeutic intervention and it could also proceed through enhancing
awareness and self-regulation—factors that have an impact on one’s vol-
untary overt behavior, including parental behavior—and altering proce-
dural knowledge and one’s internal working model (Lyons-Ruth, Bronf-
man, & Parson, 1999). In other words, a better integration of experience,
built with the therapist should increase flexibility of the patient’s thought
processes, while better self-regulation may put patients on the road to
eventual development of secure attachment behaviors (Levy et al.,
2006). Attachment theory can usefully inform clinical thinking by en-
couraging therapists to take the patient’s attachment pattern into ac-
count when selecting a treatment approach (McBride, Atkinson, Quilty,
& Bagby, 2006).
To integrate different approaches, attachment theory has led to several
branches of research to communicate and it has become a fundamental
principle of Integrative Psychotherapy. In fact, in the sphere of psycho-
therapy there are many models that consider the importance of attachment
theory (Psychoanalysis, Cognitive Psychology, Systemic Approach, etc.),
and they are linked by regarding the child’s primary relationship patterns
as innate (Liotti, 2000, 2002).
As regards attachment and psychoanalytic developments, Fonagy (Fon-
agy & Target, 1997) underlines the hallmark of secure attachment as being the
ability to reflect on one’s internal emotional experience, make sense of it, and
at the same time to reflect on the mind of another. When a caregiver reads the
verbal and nonverbal cues of the child and mirrors them back, the child looks
at him or at herself through the eyes of the attachment figure. It is through this
contingent communication process that the seeds of the development of the
self are planted and realized. Insecurely attached individuals lack this reflec-
tive function either because their emotional responses are suppressed, as in
the case of the dismissing attachment status, or exacerbated, as in the
case of the preoccupied attachment status, that is they are unable to
either identify their own internal experience or reflect on that of the
other. When either one of these extremes represents the method of
regulating the attachment behavioral system, the capacity for reflection
(on oneself and others) is compromised.
Holmes (2001) refers to the narratives—story-making and story-
breaking— of insecurely attached individuals. In the case of dismissing
attachment, where the story is so restricted as to reduce the possibility of
dysphoric affect, the clinician helps the patient in creating a story that is
coherent and full of memory and manageable affect. In the case of preoc-
cupied attachment, where anxiety overruns the client’s story, in that it
366 Giannini, Gori, De Sanctis, and Schuldberg

becomes convoluted and saturated with anger and disappointment, the

therapist’s role is to help break the negative cycle of the narrative, manage the
affect more effectively, and create a story that is balanced and coherent.
Schore (2003ab) goes beyond integration of developmental theory and
psychotherapy and describes the neuroscience of attachment and how the
brains of the parent and infant interact. Schore (Schore 2003ab) underlines the
role of neurobiology in the development of the mind during the first three
years of life and how right brain processes are integrally involved in forming
attachments and in the development of the self. He spells out clearly how
insensitive parenting leads to emotion dysregulation patterns in childhood and
later in adulthood. He understands insecure attachment as emotion dysregu-
lation, and therefore the goal of psychotherapy is the learning new capacities
to manage attachment distress; for Schore, psychotherapy is the process of
changing the brain neural patterns, involving the right brain in particular.
Siegel (1999) expanded the understanding of how attachment relation-
ships and the brain respectively influence each other. Siegel focused his work
on how the right and left brain work together— or don’t in the case of insecure
attachment—to create a coherent life story and way of responding to relation-
ships and life. All of these authors expanded the comprehension of how to
incorporate the vast body of knowledge that has accumulated in the area of
attachment theory into the practice of psychotherapy.
Slade (1999) supports the issue of how attachment theory is relevant to
clinical practice by stating, “In essence, attachment categories do tell a story.
They tell a story about how emotion has been regulated, what experiences
have been allowed into consciousness, and to what degree an individual has
been able to make meaning of his or her primary relationships” (p. 585).
Considering attachment as a principal link of the main psychotherapy
models—as a foundation of psychotherapy integration—this study describes
the creation of a new measure of Attachment styles in accordance with the
social personality perspective and the recent advances in psychotherapy inte-
gration (Castonguay & Hill, 2006; Gold & Stricker, 1993; Goldfried, 1980,
1991; Ingram, 2006; Norcross & Goldfried, 2005; Stricker & Gold, 2006;
Wachtel, 1977, 1997, 2008) and demonstrates the psychometric properties of
the Psychological Treatment Inventory (PTI) Attachment Styles Scale (ASS).

Measurement of Attachment Patterns in Adulthood

The measurement of internal working models of attachment is a com-

plex area, and within the broad area of attachment and mental health, two
streams of adult attachment literature and research have emerged. The first
one is grounded in developmental research and has been concerned with
Pspychometric Properties of the PTI-ASS 367

child–parent attachment. The second one is based in social personality

research and takes into consideration attachment in the arena of romantic
relationships (Hazan & Shaver, 1987; Shaver, Collins, & Clark, 1996).
Thus, the first approach pays attention to mental states of attachment and
the second one pays attention to relational styles.
The developmental perspective on adult attachment is derived from
the fundamental aspects of Bowlby’s attachment theory (1969, 1973, 1980)
and on individual difference in attachment as explicated by Ainsworth
(Ainsworth, Blehar, Waters, & Wall, 1978) and Main (Main & Solomon,
1986, 1990). Ainsworth and colleagues demonstrated that a child’s quali-
tatively different experience of receiving care from the attachment figure
becomes organized into discrete behavioral and mental representational
patterns: secure, avoidant, ambivalent and disorganized (Ainsworth et al.,
1978; Main & Solomon, 1986, 1990). In line with this approach internal
working models of attachment can be revealed by activating the attach-
ment system (mainly by using interviews) and then viewing the styles
through the lens of a particular form of assessment. Based on analyses of
adults’ descriptions of their childhood experience with attachment figures
in the Adult Attachment Interview (AAI; George, 1996; George, Kaplan,
& Main, 1984, 1985), Main and Goldwin (1991, 1994) identified four
categories of adult attachment, analogous to those of child attachment.
Although the behavioral expressions of the four infant attachment groups
change over the course of childhood, these clusters are characterized by the
same core representational features across the life span (West & George,
1999).
The social personality perspective on adult attachment analyzes attach-
ment patterns by studying adult romantic relations, viewing attachment
pattern as a model of intimacy, loneliness, and general relatedness.
Coming from a background of social rather than developmental psy-
chology, self-report measures of adult attachment patterns in the context of
romantic relationships are widely used (Hazan & Shaver, 1987). Self-report
measures (e.g., Bartholomew & Horowitz, 1991; Hazan & Shaver, 1987)
attempt to assess adults’ typical models of forming close relationships; they
access attachment styles that, by definition, reflect only those aspects of
internal working models that are within the individual’s conscious aware-
ness. Self-report attachment measures are easier to score and analyze than
interview procedures, and this makes them easier to use in larger-scale
research. They may also be useful in the clinical setting, whereas the Adult
Attachment Interview, because of its complexity, has remained primarily a
research tool. However, the use of self-report questionnaires has been
challenged on the basis of their (theoretically) limited ability to tap into
unconscious attachment strategies and their vulnerability to defensive
reporting. The Adult Attachment Interview (AAI; George, 1996; George,
368 Giannini, Gori, De Sanctis, and Schuldberg

Figure 1. Quadripartite Model of Attachment at the basis of the PTI.

Kaplan, & Main, 1984, 1985) by its design, does not suffer from these
deficiencies. However, in support of self-report measures, it can be coun-
ter-argued that adults are able to provide valuable information about their
emotional experiences, that most adults have sufficient experience in close
relationships to recount how they behave in them, and that conscious and
unconscious processes normally operate together to achieve any particular
goal.
The construct validity of self-report measures of romantic attachment
derives from their prediction in three domains: differential behaviors
within relationships consistent with attachment theory (e.g., the use of a
partner as a secure base); the differing attributions made by secure and
insecure individuals in relational conflicts; and, general adjustment and—as
we shall see—psychopathology (Crowell, Fraley, & Shaver, 1999). At the
Pspychometric Properties of the PTI-ASS 369

same time, self-report measures of romantic attachment show only mod-

erate correlations with measures of personality and relationship satisfac-
tion, suggesting sufficient discriminant validity (Crowell, Fraley, & Shaver,
1999). In general, the utility of self-report measurement lies on the fact that
auto-administered tests are more flexible and adaptable to typical settings
(Slade, Thornincroft, & Glover, 1999); they are easy to use, and they allow
eliminating factors of distortion due to the presence of the observer; they
can directly access the participants lives and feelings (Derogatis, 1983); and
they are the type of instruments most used in the area of psychotherapy
research (Hill & Lambert, 2004).
Hazan and Shaver (1987) found that self-report measures generally
identify two dimensions of attachment, avoidance and anxiety. Discrimi-
nant function analysis using these two dimensions placed adults into the
same groups originally identified by Ainsworth in her model.
In line with this approach, Brennan and colleagues (Brennan, Clark, &
Shaver, 1998) created the Experience in Close Relationship Questionnaire
(ECR), a self-report measure that assesses the two dimensions of “Avoid-
ance” and “Anxiety.” In the Italian version, authors demonstrated, in a
sample of 907 subjects, good values of reliability (Cronbach’s alpha ⫽ .89,
for both of the factors) and high item-total correlations; only items 15 and
22 have a lower item-total correlations of .36 and .34, respectively. With
regard to a convergent validity between the ECR and the Relationship
Questionnaire (RQ; Bartholomew, 1990; Bartholomew & Horowitz, 1991),
other authors have shown that RQ’s “Avoidant” style scores correlated
(r ⫽ .29; p ⬍ .001) with the “Avoidance” factor of ECR, while the
“Worried” style of the RQ results correlated (r ⫽ .37; p ⬍ .001) with
“Anxiety” on the ECR. In addition, the RQ’s “Avoiding timid” style scores
correlated both with “Anxiety” (r ⫽ .33; p ⬍ .001) and with “Avoidance”
(r ⫽ .36; p ⬍ .001) on the ECR. Moreover, both of the ECR’s factors
showed negative correlations with the “Secure” style of the RQ, respec-
tively .14 for “Avoidance” and .26 for “Anxiety.”
More recently, Bartholomew, following a somewhat different ap-
proach, developed an adult attachment typology to describe intimate re-
ciprocal interactions (Bartholomew & Horowitz, 1991; Griffin & Bar-
tholomew, 1994; Sharfe & Bartholomew, 1995). She defined attachment “in
terms of the intersection of two underlying dimensions of internal working
models, positivity of models of the self and positivity of models of hypothet-
ical others, resulting in four attachment patterns” (Sharfe & Bartholomew,
1995, p. 394).
In this direction, the Attachment Style Questionnaire (ASQ; Feeney,
Noller, & Hanrahan, 1994) represents one attempt to overcome the short-
comings of a categorical approach to measuring attachment (see Allen,
370 Giannini, Gori, De Sanctis, and Schuldberg

Stein, Fonagy, Fultz, & Target, 2005; Heiss, Berman, & Sperling, 1996).
The ASQ was theoretically inspired by Bartholomew’s (1990) and Bar-
tholomew and Horowitz’s (1991) research and their methodology.
The ASQ showed five dimensions: Confidence, which reflects secure
attachment, and Preoccupation with Relationships, Relationships as Sec-
ondary (to achievement), Discomfort with Closeness, and Need for Ap-
proval, all four of which represent particular aspects of insecure attach-
ment. These five attachment styles do not map directly into the two-axis,
four-category attachment model of Bartholomew (1990) and Bartholomew
and Horowitz (1991). Some rough correspondences may, however, be
approximated as follows: the “Confidence” style signifies secure attach-
ment; “Preoccupation with relationships” is a principal aspect of Bar-
tholomew & Horowitz’s (Bartholomew, 1990; Bartholomew & Horow-
itz, 1991) preoccupied group and of Hazan and Shaver’s (1987) anxious/
ambivalent form of attachment; “Relationships as secondary (to
achievement)” reflects Bartholomew and Horowitz’s conceptualization
of the dismissing attachment style (Bartholomew, 1990; Bartholomew &
Horowitz, 1991); “Discomfort with closeness” relates to the two cate-
gories of Bartholomew and Horowitz (Bartholomew, 1990; Bar-
tholomew & Horowitz, 1991) obtained by adhering to a negative model
of the other (high avoidance), and therefore more appropriately relates
to the avoidant category in Hazan and Shaver’s (1987) three-category
model; “Need for approval” relates to the two categories in Bar-
tholomew and Horowitz (Bartholomew, 1990; Bartholomew & Horow-
itz, 1991) obtained by adhering to the negative model of self (high
dependence), as discussed in Chotai et al. (2005; see also Barbara &
Dion, 2000; Feeney et al., 1994).
A previous study (Feeney et al., 1994) of 470 students demonstrated high
levels of internal consistency (Cronbach’s alphas ranging from .76 to .84), and
test–retest reliabilities over a 10-week period ranged from .67 to .78.
Data for the Italian version (Fossati et al., 2003) also indicated high
reliability within each dimension (Cronbach’s alphas from .67 to .74, in the
clinical sample and from .64 to .73, in the nonclinical sample) and test–
retest reliabilities over a one-month period of .54, .79, .66, .60, .74, respec-
tively for Confident, Discomfort with closeness, Relationships as second-
ary, Need for approval, and Preoccupation with relationships.
Following in the footsteps of the social perspective, which analyzes
attachment pattern in adult romantic relations, we describe the creation of
a new self-report instrument designed for the repeated measurement of
client status over the course of therapy and at termination, which assesses
the four dimensions of attachment theorized by Ainsworth et al. (1978) and
Main, Kaplan, and Cassidy (1985).
Pspychometric Properties of the PTI-ASS 371

A New Self-Report Measure of Attachment:

The PTI Attachment Styles Scale (ASS)

The Psychological Treatment Inventory Attachment Styles Scale (PTI-

ASS; Gori, Giannini, & Schuldberg, 2008) was designed to measure the
kind of romantic relationship people become involved in as well as the
correlated behaviors, emotions, and thoughts that could be derived from
conscious drives. By evaluating these components, the PTI Attachment
Styles Scale (ASS) assesses the related attachment style from among the
categories of secure, ambivalent, avoidant, and unresolved.
The secure style is characterized by comfort with closeness and ab-
sence of fear of abandonment. Secure individuals are comfortable being
close to their partners.
The preoccupied or ambivalent style is characterized by fear of aban-
donment and wanting to be closer to others than they would like. Anxious
adults are constantly worried or anxious about their love lives—they create
and desperately need intimacy—and they are preoccupied that their part-
ners will leave them.
The avoidant style is characterized by discomfort with closeness and
dependence and a feeling that others want to be “too close.” These
individuals do not invest much emotion in relationships and experience
little distress when a relationship ends. Other common characteristics
include a failure to support partners during stressful times and an inability
to share feelings, thoughts, and emotions with partners.
Unresolved individuals are also uncomfortable with intimacy, and they
actually fear it. People with this attachment style have mixed feelings about
close relationships. They desire to have emotionally close relationships; how-
ever, on the other hand, they tend to feel uncomfortable with emotional
closeness. These mixed feelings are combined with negative views about
themselves and their partners. These individuals generally had a sort of “bad
and good” relationship with their parents, consisting of neglectful treatment by
their parents, mixed with other, more positive behavior from them.
All of these characteristics, belonging to the four different kinds of
attachment style, can be organized into a hierarchical scheme, starting from
attachment styles that connote specific types of personalities (see Figure 1);
as we have often said, attachment styles generate typical internal working
models that are patterns of relations on which people base their expecta-
tions about interactions and which influence the views of the self and others
and that flow into an actual cognitive schema. The latter could be consid-
ered a state of the mind or a prototypic way of thinking, depending on a
number of similar interaction and experiences, that accompany a person
during all of his or her daily life and which expresses themselves, at a
372 Giannini, Gori, De Sanctis, and Schuldberg

practical level, in particular relational script or ploy. Therefore, there is a

strong link among attachment styles, the way a person lives the self and
with others, and the person’s predominant thoughts and related actions;
each of these elements influences the others directly or indirectly but
always contributes to forming a unity that is the person, with feelings,
thoughts, and behaviors. Thanks to this reciprocal effect, it is possible to
consider those aspects that characterizing the various attachment styles and
to analyze them to measure the construct in a complete way.
People with secure attachment are able to build secure relationships
that are trustworthiness-based because they have a positive sense of self
and others; therefore they are confident with an active research of prox-
imity that characterizes all their interactions (see Figure 1).
In contrast, people with a unresolved attachment style think that all
relationships are dangerous and consider other people as very frightening.
In this context the model of the self is ambivalent, at the same time both
strong and once weak; the predominant feeling is hostility and the related
strategy is distancing (see Figure 1).
In addition, the avoidant style is connoted by difficult relationships;
these kind of people underestimate others and do not give prominence
to their interactions with them, so the “other” is believed as inaccessible
and the self is lived sometimes as positive and sometimes as negative;
this is so much the case that a state of irritation predominates. At a
practical level there is a continuous recourse to separation and detach-
ment strategies (see Figure 1).
At the minimum, preoccupied attachment subjects live their relation-
ships as unstable and uncertain, because of the fact that they perceive a
sense of the self as loveable only under specific conditions that are not
predictable in others. This contributes to creating a feeling of dependence
or a fear of being abandoned, which makes people establish a strong sense
of closeness and manipulate relationships (see Figure 1).
Considering all these characteristics and translating them into specific
element of investigation, the PTI Attachment Styles Scale (ASS) is com-
posed of 22 items that are intended to assess what kind of romantic
relationship people are able to establish, as well as their behaviors, feelings,
and opinions about close relationships. The intent is to infer the linked
attachment style via assessing conscious derives.
For each factor the number of items was chosen to favor the dimension-
ality for the scales (with one factor overdetermined). In fact, for constructing
a brief instrument we hypothesized that a number of variables from five to six
(depending on the dimension) would be sufficient to represent each factor, in
reasons of the literature and of Factor Analysis (FA) criteria.
The response format adopted was a Likert scale with five points (from
1 ⫽ “Not at all” to 5 ⫽ “A great deal”). The item scores are then summed
Pspychometric Properties of the PTI-ASS 373

for each dimension and compared with descriptive parameters from a

normative sample.
This study aims to evaluate the psychometric properties of the PTI
attachment styles scale.

METHOD

Participants and Procedure

Participants of this study were 566 persons (51.6% male, 48.4% fe-
male) with a ages ranging from 18 to 63 years (M ⫽ 31.4; SD ⫽ 10.8),
divided into two groups: 1) a nonclinical sample composed of 521 subjects
(54.9% male, 48.4% female) with a mean age of 31.9 (SD ⫽ 10.8), and 2)
a clinical sample composed of 45 patients (17.8% male, 82.2 female) with
a mean age of 26.33 years old (SD ⫽ 9.27). The first group of participants
(nonclinical sample) was a convenience sample recruited for this study. The
second group of participants (n ⫽ 45) was composed of patients with
diagnoses of eating disorders. These subjects were recruited in two italian
centers specializing in eating disorder treatments. All participants were
Italian and completed the PTI Attachment Styles Scale in booklet form.
For the nonclinical sample (Group 1), the instruments were adminis-
tered in both individual and group formats. To verify some aspects of
concurrent validity, a portion of the nonclinical sample (Group 1), com-
posed of 60 subjects with a mean age of 33.2 years (SD ⫽ 12.3), completed
the PTI Attachment Styles Scale (ASS), the Italian version of the Experi-
ence in Close Relationship Questionnaire (ECR), and the Italian version of
the Attachment Style Questionnaire (ASQ).
For what concerns the clinical sample (Group 2) the procedures of
administration were developed by the psychiatrics and psychotherapists
involved in the treatment of these patients. To verify some aspects of
Discriminant Validity, this clinical sample (Group 2) completed the PTI
Attachment Styles Scale (ASS).
All participants, who were volunteers, provided information about age,
sex, gender, educational level, and professional activities and completed an
informed consent form after the intake assessment.

Measures

In this study we used the PTI Attachment Styles Scale (PTI-ASS; Gori,
Giannini, & Schuldberg, 2008) and, to verify some aspects of concurrent
374 Giannini, Gori, De Sanctis, and Schuldberg

validity, the Italian version of the Experience in Close Relationship Ques-

tionnaire (ECR; Brennan, Clark, & Shaver, 1998), edited by Picardi and
colleagues (2002), as well as the Italian version of the Attachment Style
Questionnaire (ASQ; Feeney, Noller, & Hanrahan, 1994), edited by Fos-
sati and colleagues (2003).
The PTI Attachment Styles Scale (ASS) is composed of 22 items, with
a Likert scale format with five points (from 1 ⫽ “Not at all” to 5 ⫽ “A great
deal”), which are intended to assess the related attachment style from
among the categories of secure, ambivalent, avoidant, and unresolved.
The Experience in Close Relationship Questionnaire (ECR) is a self-
report measure composed of 36 item with a Likert scale response format
with seven points (from 1 ⫽ “Completely False” to 7 ⫽ “Completely true”)
and includes two scales of 18 items each that respectively assess the
dimension of “Avoidance” and “Anxiety.” For scoring purposes responses
are summed, and high scores on one of the scales indicate that the subject
has a high level of the Anxious or Avoidant factors of attachment (the
range is from 18 to 126).
The Attachment Style Questionnaire (ASQ) contains 40 items, and
participants rate each item on a six-point Likert scale (From 1 ⫽ “Totally
disagree“ to 6 ⫽ “Totally agree”) . Exploratory Factor Analysis (EFA) of
the ASQ showed five dimensions (Feeney et al., 1994), with 43.3% of the
total variance explained. One scale, Confidence, reflects secure attachment,
and the other four represent particular aspects of insecure attachment and
are named Preoccupation with Relationships, Relationships as Secondary
(to achievement), Discomfort with Closeness, and Need for Approval.

Data Analysis

To investigate the distribution of the data in the sample, descriptive

statistics were calculated.
We used factor analysis to identify attachment dimensions, with the
objective of assessing the validity of the hypothesized constructs. Thus, in
a part of the sample (n ⫽ 300), a series of Exploratory Factor Analysis
(EFA) with Principal Axis Factor (PAF) analyses was conducted to verify
the factor structure of the Attachment Styles Scale. In the other part of the
sample (n ⫽ 266) we applied Confirmatory Factor Analysis (CFA). To
evaluate the model’s goodness of fit, a number of indexes were used.
Because the chi-square fit index depends on sample size (Schermelleh-
Engel, Moosbrugger, & Muller, 2003), two relative fit indexes of fit were
considered because of they appear appropriate for uses in both large and
small samples: the NNFI (Non-Normed Fit Index) and the CFI (Compar-
Pspychometric Properties of the PTI-ASS 375

ative Fit Index). Higher values of these indexes more than .95 can be
considered as indicating satisfactory fit (Schermelleh-Engel, Moosbrugger,
& Muller, 2003). In addition, the root mean square error of approximation
(RMSEA) has been used as an absolute index of fit that allows evaluation
of the approximation of estimated parameters in relation to those of the
normal population. Reliability for each scales was calculated using the
Cronbach’s alpha coefficient (Cronbach, 1951).
Several aspects of concurrent validity were verified using the Pearson’s
r coefficient, and discriminant validity was assessed using t tests comparing
the clinical group (n ⫽ 45) and a part of the nonclinical group (n ⫽ 45
randomly selected participants).

RESULTS

Examination of the scree plot (Cattell, 1966), percentage of variance

accounted for, and parallel analysis (Glorfeld, 1995; Horn, 1965; Zwick &
Velicer, 1986) indicated that as many as four factors should be retained for
rotation. Results of Exploratory Factor Analysis (EFA) (Varimax Ro-
tation) showed a factor structure with four principal dimensions (eigen-
values ⬎ 1; 5.12, 3, 2.42, 1.9), with 56.58% of total variance explained.
The Factor Structure Matrix shows the four independent factors of the
scales (see Table 1).
The goodness-of-fit indices showed a good fit to the data; although the
chi-square was significant (p ⬍ .001), the other goodness-of-fit indexes
showed satisfactory values (NNFI ⫽ .97; CFI ⫽ .97; RMSEA ⫽ .07).
The reliability of the scales, calculated using the Cronbach’s alpha
coefficient, indicated good values of internal consistency (Secure, ␣ ⫽
.80; Preoccupied, ␣ ⫽ .81; Avoidant, ␣ ⫽ .75; Unresolved, ␣ ⫽ .80). The
internal consistency of the insecure patterns was also calculated and was
␣ ⫽ .77. Item–total correlation values ranged from .31 (item 11) to .78
(item2).
The PTI Attachment Styles Scale (ASS) showed strong correlations
with the Italian version of the Experience in Close Relationship Question-
naire (ECR) and the Italian version of the Attachment Style Questionnaire
(ASQ). Correlations between the PTI ASS factors Avoidant and Preoccu-
pied scales with, respectively, the ECR Avoidance and Anxiety factors,
were positive and statistically significantly (see Table 2).
In addition, correlations among the PTI AAS factors and ASQ dimen-
sions showed good values (see Table 3).
The t test results showed that the clinical group obtained significantly
higher values for insecure attachment patterns than the nonclinical group and
376 Giannini, Gori, De Sanctis, and Schuldberg

Table 1. Factor Strucure Matrix (Varimax Rotation)

PTI Attachment Styles Scale (ASS) Factors
Items Secure Preoccupied Avoidant Unresolved
Item 13 .82
Item 10 .79
Item 5 .70
Item 16 .55
Item 1 .52
Item 4 .82
Item 18 .75
Item 7 .75
Item 20 .62
Item 15 .52
Item 17 .80
Item 9 .66
Item 3 .62
Item 21 .61
Item 14 .53
Item 11 .41
Item 6 .73
Item 2 .67
Item 12 .67
Item 19 .60
Item 22 .58
Item 8 .53

obtained lower values for scales that concern the secure style of attachment.
All of these differences were statistically significant (see Table 4).

DISCUSSION

The aim of this work was to illustrate the theoretical principles of the
Psychological Treatment Inventory Attachment Styles Scale (PTI-ASS;
Gori, Giannini, & Schuldberg, 2008) and to verify its psychometric char-
acteristics (factor structure, reliability, and validity). The importance of
creating a new scale to assess attachment styles lies in the fact that attach-
ment theory provides an empirically grounded framework for understand-

Table 2. Aspects of Concurrent Validity (n ⫽ 60): Correlation Between PTI

AAS and ECR
PTI Attachment Styles Scale
ECR Factors 1 (Secure) 2 (Preoccupied) 3 (Avoidant) 4 (Unresolved)
ⴱ ⴱ
Avoidance ⫺.27 ⫺.13 .29 ⫺.21
Anxiety ⫺.29ⴱ .45ⴱⴱ ⫺.22 .14
ⴱ ⴱⴱ
p ⬍ .05. p ⬍ .01.
Pspychometric Properties of the PTI-ASS 377

Table 3. Aspects of Concurrent Validity (n ⫽ 60): Correlation Between PTI

AAS and ASQ
PTI Attachment Styles Scale
1 2 3 4
ASQ Factors (Secure) (Preoccupied) (Avoidant) (Unresolved)
Confidence .68ⴱⴱ ⫺.21 ⫺.32ⴱ ⫺.41ⴱⴱ
Discomfort with closeness ⫺.29ⴱ .27ⴱ .51ⴱⴱ .21
Need for approval ⫺.31ⴱ .28ⴱ ⫺.12 .13
Preoccupation with relationships ⫺.22 .48ⴱⴱ ⫺.14 .22
Relationships as secondary ⫺.18 .21 .39ⴱⴱ ⫺.18
ⴱ ⴱⴱ
p ⬍ .05. p ⬍ .01.

ing important aspects of interpersonal functioning, in children as well as

adults. In fact, recently attachment theory has found increasing use within
the field of individual psychotherapy with adults.
Even though research on adult attachment patterns in individual psy-
chotherapy is still in its infancy, the growing number of empirical studies
clearly supports the relevance of adult attachment to psychotherapy pro-
cess and outcome (Daniel, 2006). The existing studies have linked the
attachment patterns of clients and also of therapists to differences in
in-treatment behavior, in the quality and development of the therapeutic
alliance, and in therapeutic outcome.
Client attachment patterns can be relevant to psychotherapy outcome
in at least two ways. First, clients with certain attachment patterns may fare
better in psychotherapy or in particular forms of psychotherapy than other
clients or with specific types of therapists. At the same time, because of the
link between insecure attachment patterns and psychological problems, it
may well be interesting to look at psychotherapy outcome in terms of
change in attachment patterns. That is, adult attachment classification
might be used as an outcome measure in itself.
In line with this, we created a measure of attachment styles useful for
the repeated measurement of client status over the course of therapy and
at termination. This PTI Attachment Styles scale is a brief (22-item)
self-report measure that can be adapted to different clinical settings. In

Table 4. Aspects of Discriminant Validity (n ⫽ 45): t Tests Between the Two Groups
Clinical group Nonclinical
(n ⫽ 45) group (n ⫽ 45)
Attachment styles M SD M SD t df p
1) Secure 16.12 3.56 18.8 4.85 ⫺5.15 44 .001
2) Preoccupied 18.58 4.65 12.68 4.23 20.43 44 .001
3) Avoidant 15.12 6.19 11.87 4.15 6.09 44 .001
4) Unresolved 10.13 4.72 7.24 3.42 5.28 44 .001
378 Giannini, Gori, De Sanctis, and Schuldberg

fact, theoretical principles behind the PTI make possible its use in different
settings and by clinicians of different orientations.
In the present research the PTI ASS showed a clear and clinically (and
theoretically relevant) factor structure with four independent and robust
dimensions conceptualized as Secure, Preoccupied, Avoidant, and Unre-
solved attachment styles. Each dimension showed good values of internal
consistency. With regard to aspects of Concurrent Validity the PTI ASS
showed strong correlation with two of the most common self-report mea-
sure used for the assessment of attachment in adults, the ECR and the
ASQ. Finally, the PTI ASS showed good levels of Discriminant Validity,
and this testifies to the ability of the scales to distinguish between clinical
and normal population.
These results suggest that this new, brief, and easily administered and
scored instrument for assessing attachment styles in adults has good psy-
chometric properties. Thanks to these properties, it can be adopted use-
fully in both research and practice.

REFERENCES

Ainsworth, M. D. S., Bleahr, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A
psychological study of the strange situation. Hillsdale, NJ: Erlbaum.
Allen, J. G., Stein, H., Fonagy, P., Fultz, J., & Target, M. (2005). Rethinking adult attachment:
A study of expert consensus. Bulletin of the Menninger Clinic, 69, 59 – 80.
Barbara, A. M., & Dion, K. L. (2000). Breaking up is hard to do, especially for strongly
”preoccupied” lovers. Journal of Personal and interpersonal Loss, 5, 315–342.
Bartholomew, K. (1990). Avoidance of intimacy: An attachment perspective. Journal of
Social and Personal Relationships, 7, 147–178.
Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test
of a four-category model. Journal of Personality and Social Psychology, 61, 226 –244.
Bowlby, J. (1969). Attachment and loss. Vol 1. Attachment. New York, NY: Basic Books.
Bowlby, J. (1973). Attachment and loss. Vol 2. Separation. New York, NY: Basic Books.
Bowlby, J. (1980). Attachment and loss. Vol 3. Loss, sadness, and depression. New York, NY:
Basic Books.
Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development.
New York, NY: Basic Books.
Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self –report measurement of adult
attachment: An integrative overview. In J. A. Simpson & W. S. Rholes (Eds.), Attachment
theory and close relationships. New York, NY: Guilford Press.
Bretherton, I. (1985). Attachment theory: Retrospect and prospect. In I. Bretherton & E.
Waters (Eds.), Growing points of attachment theory and research (Monographs of the
Society for research in Child Development). Chicago, IL: University of Chicago Press.
Castonguay, L. G., & Hill, C. E (Eds.). (2006). Insight in psychotherapy. Washington, DC:
American Psychological Association Press.
Cattell, R. B. (1966). The scree test for the number of factors. Multivariate Behavioral
Research, 1, 245–276.
Chotai, J., Jonasson, M., Hägglöf, B., & Adolfsson, R. (2005). Adolescent attachment styles
and their relation to the temperament and character traits of personality in a general
population. European Psychiatry, 20, 251–259.
Collins, N. L., & Read, S. J. (1994). Cognitive representations of attachment: The structure
Pspychometric Properties of the PTI-ASS 379

and function of working models. In K. Bartholomew & D. Perlman (Eds.), Advances in

personal relationships: Vol. 5. Attachment processes in adulthood (pp. 53–90). London,
UK: Jessica Kingsley.
Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16,
297–334.
Crowell, J. A., Fraley, R. C., & Shaver, P. R. (1999). Measurement of individual differences
in adolescent and adult attachment. In J. Cassidy & P. R. Shaver (Eds.), Handbook of
attachment: Theory, research, and clinical applications (pp. 434 – 465). New York: The
Guilford. Press.
Daniel, S. I. F. (2006). Adult attachment patterns and individual psychotherapy: A review.
Clinical Psychology Review, 26, 968 –984.
David, D., & Szentagotai, A. (2006). Cognitions in cognitive-behavioral psychotherapies;
toward an integrative model. Clinical Psychology Review, 26, 284 –298.
Derogatis, L. R. (1983). SCL-90-R: Administration, scoring and procedures manual-II. Balti-
more, MD: Clinical Psychometric Research.
Farber, B. A., Lippert, R. A., & Nevas, D. B. (1995). The therapist as attachment figure.
European Psychiatry, 32, 204 –212.
Feeney, J., & Noller, P. (1990). Attachment style as a predictor of adult romantic relation-
ships. Journal of Personality and Social Psychology, 44, 69 –74.
Feeney, J. A., Noller, P., & Hanrahan, M. (1994). Assessing adult attachment. In M. B.
Sperling & W. H. Berman (Eds.), Attachment in adults: Clinical and developmental
perspectives (pp. 128 –152). New York, NY: Guilford Press.
Fonagy, P., & Target, M. (1997). Attachment and reflective function: Their role in self-
organization. Development and Psychopathology, 9, 677– 699.
Fossati, A., Feeney, J. A., Donati, D., Donini, M., Novella, L., Bagnato, M., . . . Maffei, C.
(2003). On the dimensionality of the Attachment Style Questionnaire in Italian clinical
and nonclinical participants. Journal of Social and Personal Relationships, 20, 55–79.
George, C. (1996). A representational perspective on child abuse and prevention: Internal
working models of attachment and caregiving. Child Abuse and Neglect, 20, 411– 424.
George, C., Kaplan, N., & Main, M. (1984). Attachment interview for adults. Berkeley, CA:
University of California.
George, C., Kaplan, N., & Main, M. (1985). Adult attachment interview. Unpublished manu-
script. University of California, Berkeley.
Glorfeld, L. W. (1995). An improvement on Horn’s parallel analysis methodology for select-
ing the correct number of factors to retain. Educational and Psychological Measurement,
55, 377–393.
Gold, J. R., & Stricker, G. (1993). Psychotherapy integration with personality disorders. In G.
Stricker & J. R. Gold (Eds.), Comprehensive handbook of psychotherapy integration (pp.
323–336). New York: Plenum.
Goldfried, M. R. (1980). Toward delineation of therapeutic change principles. American
Psychologist, 35, 991–999.
Goldfried, M. R. (1991). Research issues in psychotherapy integration. Journal of Psycho-
therapy Integration, 1, 5–25.
Gori, A., Giannini, M., & Schuldberg, D. (2008, May). Mind and body together? A new
measure for planning treatment and assessing psychotherapy outcome. Paper presented at
the SEPI XXIV Annual Meeting, Boston.
Griffin, D., & Bartholomew, K. (1994). Models of self and other. Fundamental dimensions
underlying measures of adult attachment. Journal of Personality and Social Psychology,
67, 430 – 435.
Hazan, C., & Shaver, P. (1987). Conceptualizing romantic love as an attachment process.
Journal of Personality and Social Psychology, 52, 511–524.
Heiss, G. E., Berman, W. H., & Sperling, M. B. (1996). Five scales in search for a construct:
Exploring continued attachment to parents in college students. Journal of Personality
Assessment, 67, 102–115.
Hill, C. E., & Lambert, M. J. (2004). Methodological issues in studying psychotherapeutic
processes and outcome. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of
psychotherapy and behavior change (pp.55–71). New York: Wiley.
380 Giannini, Gori, De Sanctis, and Schuldberg

Hoagwood, K., & Jensen, A. (1996). Outcomes of mental health care for children and
adolescent. Journal of the American Academy of Child and Adolescent Psychiatry, 35,
1055–1063.
Holmes, J. (2001). In search of the secure base. London: Routledge.
Horn, J. L. (1965). An empirical comparison of methods for estimating factor scores. Edu-
cational and Psychological Measurement, 25, 313–322.
Ingram, B. L. (2006). Clinical case formulations: Matching the Integrative Treatment Plan to the
Client. Hewitt, NJ: Wiley Press.
Levy, K., Clarkin, J., Yeomans, F., Scott, L., Wasserman, R., & Kernberg, O. (2006). The
mechanisms of change in the treatment of borderline personality disorder with trans-
ference focused psychotherapy. Journal of Clinical Psychology, 62, 481–501.
Liotti, G. (2000). Disorganized attachment, models of borderline states, and evolutionary
psychotherapy. In P. Gilbert, K. Bailey (Eds.), Genes on the couch: Essays in evolution-
ary psychotherapy (pp. 232–256). Hove: Psychology Press.
Liotti, G. (2002). The inner schema of borderline states and its correction during psychother-
apy: A cognitive-evolutionary approach. Journal of Cognitive Psychotherapy, 16, 310 –
325.
Lyons-Ruth, K., Bronfman, E., & Parson, E. (1999). Maternal disrupted affective communi-
cation, maternal frightened or frightening behavior, and disorganized infant attachment
strategies. In J. Vondra & D. Barnett (Eds.), A typical patterns of infant attachment:
Theory, research and current directions. Monographs of the Society for Research in Child
Development, 64, 67–96.
Main, M., & Goldwin, R. (1991). Adult attachment classification system. Version 5. Unpub-
lished manuscript. University of California, Berkeley.
Main, M., & Goldwin, R. (1994), Adult attachment scoring and classification system. Unpub-
lished manuscript. University of California, Berkeley.
Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood and adulthood: A
move to the level of representation. Monographs of the Society for Research in Child
Development, 50, 66 –107.
Main, M., & Solomon, J. (1986). Discovery of a new, insecure-disorganized/disoriented
attachment patter. In T. B. Brazelton & M. Yogman (Eds.), Affective development in
infancy. Norwood: Ablex.
Main, M., & Solomon, S., (1990). Procedures for identifying infants as disorganize/disoriented
during the Ainsworth Strange Situation. In M .T. Greemberg, D. Cicchetti, & E. M.
Cummings (Eds.), Attachment in the preschool years: Theory, research and intervention
(pp. 121–160). Chicago and London: University of Chicago Press.
Mallinckrodt. B., Gantt, D. L., & Coble, H. M. (1995). Attachment patterns in the psycho-
therapy relationship: Development of the Client Attachment to Therapist scale. Journal
of Counseling Psychology, 42, 307–317.
McBride, C., Atkinson, L., Quilty, L., & Bagby, R. M. (2006). Attachment as moderator of
treatment outcome in major depression: A randomized control trial of interpersonal
psychotherapy versus cognitive behavior therapy. Journal of Consulting and Clinical
Psychology, 74, 1041–1054.
Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integration
(2nd ed.). New York, NY: Oxford.
Parish, M., & Eagle, M. N. (2003). Attachment to the therapist. Psychoanalytic Psychology,
20, 271–286.
Picardi, A., Vermigli, P., Toni, A., D’Amico, R., Bitetti, D., & Pasquini, P. (2002). Further
evidence of the validity of the Italian version of the questionnaire Experiences in Close
Relationships (ECR), a self-report instrument to assess adult attachment. Italian Journal
of Psychopatology, 8, 282–294.
Schermelleh-Engel, K., Moosbrugger, H., & Muller, H. (2003). Evaluating the fit of structural
equation models: Tests of significance and goodness-of-fit models. Methods of Psycho-
logical Research Online, 8, 23–74.
Schore, A. N. (2003a). Affect dysregulation and disorders of the self. New York: W. W. Norton.
Schore, A. N. (2003b). Affect regulation and the repair of the self. New York: W. W. Norton.
 Pspychometric Properties of the PTI-ASS 381

Sharfe, E., & Bartholomew, K. (1995). Accommodation and attachment representations in

young couples. Journal of Social and Personal Relationships, 12, 380 – 401.
Shaver, P. R., Collins, N., & Clark, C. L. (1996). Attachment styles and internal working
models of self and relationship partner. In G. J. O. Fletcher & J. Fitness (Eds.),
Knowledge structures in close relationships: A social psychological approach.. Mahwah,
NJ: Erlbaum.
Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape
who we are. New York, NY: Guilford Press.
Slade, A. (1999). Attachment theory and research: Implications for the theory and practice of
individual psychotherapy for adults. In J. Cassidy & P. Shaver (Eds.), Handbook of
attachment: Theory, research, and clinical applications (pp. 575–594). New York, NY:
Guilford Press.
Slade, M., Thornincroft, G., & Glover, G. (1999). The feasibility of routine outcome mea-
surement. Social Psychiatry and Psychiatric Epidemiology, 34, 243–249.
Stricker, G., & Gold, J. (Eds.). (2006). A casebook of psychotherapy integration. Washington,
DC: American Psychological Association.
Wachtel, P. L. (1977). Psychoanalysis and behavior therapy: Toward an integration. New York,
NY: Basic Books.
Wachtel, P. L. (1997). Psychoanalysis, behavior therapy, and the representational world.
Washington, DC: American Psychological Association.
Wachtel, P. L. (2008). Relational theory and the practice of psychotherapy. New York, NY:
Guilford Press.
West, M., & George, C. (1999). Violence in intimate adult relationships: An attachment
theory perspective. Attachment and Human Development, 1, 137–156.
Zwick, W. R., & Velicer, W. F. (1986). Comparison of five rules for determining the number
of components to retain. Psychological Bulletin, 99, 432– 442.

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