Friday, October 7, 2011

Attachment in Therapy

Underneath the theory and technique, the heart of therapy is the relationship - a special kind of relationship that is formed between therapist and client. The incredibly personal nature of what is shared in therapy gives the relationship a very intimate quality. As a result, clients tend to relate to the therapist in a way that reflects the patterns and expectations they bring to intimate relationships. 

We call it "transference" when the client layers a specific relationship from their past or present life onto the therapeutic relationship - for example, relating to the therapist as if she were the client's actual parent/partner/child, etc. However, even without this kind of transference, we are getting flavors of how the client feels about and relates to important other people. 

This process is both incredibly important and incredibly complicated for clients who have experienced relational traumas - when they have been hurt by those who were most supposed to love and protect them. Particularly when these traumas occur early in life, people may develop enduring patterns of "insecure attachment" - basically, relational templates that assume instability, unpredictability, and/or threat within close relationships. 

While there has been plenty written about attachment styles, I have been thinking more about how insecure attachment styles reveal themselves in therapy, and wanted to write a bit about the subject from this perspective. There are three kinds of insecure attachment, described in adults as preoccupied, dismissive, and unresolved:
  1. Persons with a preoccupied attachment style are anxious about relationships, and cope with their anxiety by seeking reassurance. In romantic relationships, they may call often, ask if their partners love them or are mad at them, and so on. In therapy, they may need frequent reassurance that the therapist is "there," and will continue to be there. For example, one client of mine needs reassurance that each new adjunct service (case management, day treatment, etc) is not going to replace therapy, and is not an attempt to "get rid of her." Clients with this attachment style tend to find vacations and other cancellations or disruptions in treatment especially distressing and anxiety-provoking. They may also hold back what they consider to be the most unacceptable parts of themselves for an unusually long time, believing the therapist wouldn't continue working with them if they "really" knew them. As a result, continuity and unconditional positive regard in treatment can be immensely healing.
  2. In contrast, people with dismissive attachment styles cope with their anxiety about relationships by dismissing the importance of relationships in general, and by minimizing the significance of particular relationships by leaving the other person before that person can leave them. These clients may be extraordinarily reluctant to engage in the therapeutic relationship. For example, I have one client with some risk issues who didn't want to schedule a follow-up appointment. She needs treatment, but I was sure that encouraging her to come would be the surest way to prevent that from happening. I waited two weeks, but she finally did call to request an appointment, and I am much more confident that she will come precisely because I stepped back and didn't try to pull her in. These clients may also be inclined to drop out without warning if things start to feel too intense. However, if they can hang in their through whatever is triggering the impulse to bolt, it's another potential for significant healing.
  3. Finally, individuals with unresolved attachment styles are not consistent in a pattern of relating - they are (predictably) unpredictable. Sometimes preoccupied, sometimes dismissive, sometimes clinging while get the general idea. One client of mine copes with her fear of her partners leaving her by holding them hostage, or by leaving them first, depending on relative size and power. She abruptly dropped out of treatment with her last therapist when she sensed that the therapist was "tired" of her. The challenge for the therapist is to both be predictable in the face of unpredictability, and NOT realize the negative predictions (abandonment, rejection, or whatever).
As this last example suggests, I find it incredibly informative to ask about clients' past experiences with therapy, and how they ended. If someone seems to have dropped out just when they were getting to the heart of thing, I talk to them about relationship patterns, and how they may at some point feel like doing the same thing with me - but that they can make some real progress if they can stick with our relationship anyway. 

How do you assess for and understand the relational patterns that your clients bring to therapy? What have been the best and worst examples for you?

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