Rewriting History: Attachment Theory in the Practice of Adult Psychotherapy

Graduate Student Journal of Psychology Copyright 2015 by the Department of Counseling and Clinical Psychology 2015, Vol. 16 Teachers College, Columbia University Rewriting History: Attachment Theory in the Practice of Adult Psychotherapy

Jillian D. Farrell, B.A. Department of Counseling and Clinical Psychology Teachers College, Columbia University Jacqueline A. Carleton, PhD National Institute for the Psychotherapies

Attachment theory can enhance both the therapist’s and patient’s awareness of their roles in the psychotherapeutic process, their effect on the therapeutic alliance, and their understanding of themselves and one an- other. John Bowlby (1980) proposed that the innate developmental task of infants is to seek and grow a relationship with their primary caregiver, offering the child protection and security (Dolan et al., 1993; Farber et al., 1995; Levy, 2005; Sable, 2007). As an adult, the acquired pattern of attachment behavior guides how an individual relates to others, functions in interpersonal situations and relationships, regulates emotions, and refects on past or present attachments (Atkinson et al., 2004; Mikulincer et al., 2007; Sable, 2007; Zilcha et al., 2011). By reviewing the selected literature in the feld, the present article strives to help clinicians deepen their understanding of the role of attachment theory with adult patients, in the psychotherapeutic process, as it has been elaborated in the recent literature. It is hoped that clinicians will be inspired to follow up with some of the multitudinous references we have provided to this fascinating literature. We would also hope that they realize that a great deal of evidence has accrued of the effectiveness of attachment based psychotherapy.

Introduction conviction that early family experience is related to later personality functioning (Harris, 2004; Sable, 2007). Background The present paper strives to help clinicians deepen John Bowlby (1980), the father of attachment their understanding of the role of attachment theory theory, established a conceptual framework that con- in the psychotherapeutic process with adult patients, tinues to inspire attention and research. The princi- as it has been elaborated in the plethora of recent ples of the theory address the innate developmental literature. By reviewing selected literature in the feld, task of infants to seek and grow a relationship with knowledge and perspectives of attachment concepts their primary caregiver, offering the child protection are examined and integrated to form a comprehen- and security (Sable, 2007; Levy, 2005; Dolan et al., sive overview. The various elements of attachment 1993; Farber et al., 1995). This is congruent with the theory are discussed in the context of psychotherapy, ethological principle that all mammals require the including suggestions for the application of theory to presence of a caregiving fgure as the protector of the practice and possible directions for future research. fragile infant striving for survival (Bernier et al., 2002; Bowlby, 1980; Diener et al., 2011; Muller, 2009). Us- Signifcance of Attachment Theory in Clinical ing Bowlby’s theory as a foundation, Mary Ainsworth Practice went on to systematically assess attachment needs and The phrase “attachment state of mind” denotes behaviors of toddlers in her well-known experiment, the way an individual in adulthood processes at- The Strange Situation (Ainsworth, 1985; Ainsworth tachment-related cognitions, feelings, and memories et al., 1978). From there, Mary Main and colleagues (Atkinson et al., 2004). Attachment systems impact developed the Adult Attachment Interview (AAI), people’s trust in close relationships, their fears of re- enabling researchers and clinicians to explore at- jection, their weak or intense yearning for intimacy, tachment related phenomena in late adolescence and and their tendency to favor dependency or autono- adulthood (Wallin, 2007). An enormous amount of my (Meyer et al., 2001). The acquired pattern of at- attachment research continues to fourish and there is tachment behavior guides how he or she relates to now substantial empirical support for Bowlby’s (1980) others, functions in interpersonal situations and relationships, regulates emotions, and refects on past Keywords: attachment, psychotherapy, working alliance, AAI or present attachments (Atkinson et al., 2004; Mi-

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kulincer et al., 2007; Sable, 2007; Zilcha et al., 2011). The individuals typically exhibiting psychopa- Indeed, attachment theory offers a foundation from thology are unable to protect themselves against which a clinician can better understand the limitations and/or cope with threats, stresses of human in- and capacities of an adult patient through the consid- teraction, and the hassles of everyday life due to eration of childhood and current relationships that the absence of the fexible psychological process- have brought about the person’s representations of es developed through early attachment experienc- the self and others (Sable, 2007; Smith et al., 2009). es (Bateman et al., 2003; Bowlby, 1980; Levy, 2005; Utilizing attachment theory, an adult patient’s ca- Sable, 2007; Zilcha et al., 2011). Losses and unre- pacity to form positive relationships can be examined solved experiences in a person’s attachment system (Smith et al., 2009). In adults, psychopathology may can be kept hidden in a dissociated state that only arise from or result in the inability to form and main- releases these overwhelming experiences when pro- tain close relationships (Sable, 2007). Additionally, voked with cues relating to them (Wallin, 2007). attachment theory can be understood as a theory of trauma in which the lack of and/or disruption in se- The Modifcation of Attachment Systems in cure connections to others generates traumatic stress Psychotherapy and modifed styles of attachment (Levy, 2005). An Fortunately, attachment systems can be mod- individual’s attachment system is associated with the ifed by subsequent relationships, one of which is capacity for intersubjectivity, affect-regulation, men- psychotherapy (Mikulincer et al., 2007; Wallin, 2007; talization, and other developmental processes; thus, Zilcha et al., 2011). The experience of psychother- the disruption or weakness of these processes due apy, frst described by Freud as “the talking cure”, to a maladaptive attachment system can weigh heav- generally involves self-disclosure of concerns by ily on one’s functioning and be manifested in symp- the client and facilitation of change by the therapist toms (Bowlby, 1980; Sable, 2007). Lamagna (in press) (Leger, 1998). Vaughn and Burgoon (1976) noted, states, “This ‘internal attachment system’, compris- “Parsons (1951) maintains that therapy becomes ing states representing our subjective experience and necessary when the control mechanisms inherent states refecting on and appraising that experience in the reciprocities of ordinary human relationships coordinates its activity in ways that best regulate the break down” (p.256, quoted from Leger, 1998). Thus, individual’s affects, thoughts, perceptions, and behav- psychotherapy, particularly attachment-focused psy- ior.” Research shows a convincing connection be- chotherapy, has the potential to transform the rigid tween attachment defcits and Axis I and Axis II di- processes of one’s attachment system to become agnoses (Shorey et al., 2006). Bowlby (1980) pointed more robust, as well as re-write the way a person out long ago that separations, losses, and other distur- views him or her self and others (Harris, 2004). bances in attachment are the foundations from which The growing research in attachment is beginning emotional distress and personality disorders arise. to facilitate greater application of the theory to the practice of psychotherapy (Mikulincer et al., 2007; How Attachment Theory Is Related to Psycho- Wallin, 2007). Findings have supported the notion pathology in Adulthood that clinicians’ knowledge of attachment theory en- Wallin (2007) proposes that the guiding rules of a hances the effcacy of the therapeutic relationship person’s life are those evolved from the “rules of attach- (Farber et el., 1995). Psychotherapeutic treatment uti- ment” that were internalized and embedded in infancy lizing attachment theory provides an opportunity for through interactions with caregivers. These “rules”, in a patient to delve into both early and current attach- time, defne the means by which one accesses attachment experiences while in a safe setting and with a ment-related cognitions, emotions, and recollections. safe person: the therapist (Bowlby, 1980; Sable, 2007). The attachment they had as infants has been found Attachment theory can “enrich (rather than dictate) to be strongly linked to their psychological health the therapist’s understanding of his or her patient” as adults (Atkinson et al., 2004; Shorey et al., 2006). (Steele et al., 2008), allowing the therapeutic alliance

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and intervention techniques to be designed to match a Mallinckrodt et al., 2005; Smith et al., 2009). For ex- patient’s specifc needs (Mallinckrodt et al., 2005). ample, clients with a dismissing attachment style may be cold and unwelcoming towards the therapist at the Developmental Processes Starting In onset of therapy, making it diffcult to have a conver- Early Attachment Experiences sation. After they experience the warmth and helpful- ness of the therapist at a carefully titrated pace, these Internal Working Models of Attachment clients begin to feel more motivated and comfortable Internal working models are the foundations of sharing with the therapist and interacting in sessions. adaptive or maladaptive thoughts and behaviors (Zil- Through the internalization of the therapist cha et al., 2011). An individual’s unique internal rep- as a nurturing and reliable fgure, a client gradually resentations strongly infuence his or her behaviors builds an internal working model of the therapist and security later on in life (Bowlby, 1980; Cortina et and comes to see the therapist as an attachment fg- al., 2003; Harris, 2004; Lamagna, in press; Levy, 2005; ure that he or she can resort to during distress, at Smith et al., 2009; Zilcha et al., 2011). These internal frst through direct contact and eventually by inter- working models are organized behavioral systems and nalization (Bowlby, 1980; Farber et al., 1995). The cognitive structures developed through the internal- evocation of the therapist by the client during emo- ization of early interactions with caregivers and the tional and/or interpersonal diffculty allows for the environment (Bowlby, 1980; Cortina et al., 2003; Die- employment of affect regulation strategies and the ner et al., 2011; Harris, 2004; Levy, 2005; Meyer et al., revision of maladaptive expectations and behaviors 2001; Mikulincer et al., 2007; Sable, 2007; Zilcha et al., (Obegi, 2008). The changes in reaction to stressful 2011). Once these representations of self and others circumstances and the experience of a positive at- are formed, one’s expectations and style of thinking tachment relationship contribute to an increased are virtually automatically implemented in subsequent confdence in the self and/or others (Obegi, 2008). relationships (Diener et al., 2011; Muller, 2009). The The internalization of the benevolent role of meaning of events is constructed to be congruent the therapist and the formation of a positive in- with the inner working models, whether accurate or ternal working model of the therapist is critical to inaccurate. Negative internal working models lead to therapeutic change (Zilcha et al., 2011). Clients can the misinterpretation of social cues, like attributing reveal their internal working models through attach- hostility to others’ benign intentions (Muller, 2009). ment behaviors, transference, narratives, and self-re- In other words, as a child matures through life his ports (Harris, 2004). In the case of transference, the or her internal expectations, established from early patient actually projects his or her internal working experiences, govern the experience and navigation models onto the therapist (Smith et al, 2009). Trans- of the external world (Harris, 2004; Leger, 1998). ference can include positive manifestations that prog- The propositions of both Bowlby (1980) and in- ress treatment forward, or negative manifestations terpersonal theorists suggest that an essential goal of that may be seen as resistance (Cortina et al., 2003). therapy is the restructuring of representations of ear- Dozier and Tyrell (1998) stressed the need for the ly attachment interactions and the transformation of therapist to gently challenge the client’s attachment insecure internal working models and destructive re- patterns, assumptions about relationships, and coping lational behaviors (Diener et al., 2011). These changes strategies in order to encourage the steady exploration are thought to occur as a result of the new relationship of emotional and interpersonal issues. The goal is to experiences with the therapist (Diener et al., 2011). restructure the models to be more congruent with ac- Although initially clients’ negative working models curate and current knowledge and experiences (Sable, infuence his/her attachment and perceptions of the 2007). Dozier and Tyrell (1998) termed this process therapist, they become more secure during the course a “correctional experience”. In adult patients, there is of therapy as the client is subjected to the consistency an unconscious, active adherence to the preexisting and responsiveness of the therapist (Bowlby, 1980; “rules of attachment”. Therefore, disconfrming the

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client’s internal working models propels the client to client. In some cases, it is extremely challenging or investigate, reevaluate, and understand past experi- impossible for a therapist to provide the patient ences that have shaped his/her problematic models with the sense of security needed to establish the and representations (Eagle et al., 2006; Shorey et al., restorative positive relationship with the therapist 2006). Some label this type of intervention involving (Mallinckrodt et al., 1995; Zilcha et al., 2011). If a push for change as “purposeful misattunement” this is the case, the patient may be able, guided by (Shapiro et al., 1999). From this exploration, expec- the therapist, to use a current intimate relationship. tations and perceptions of the self and/or relationships can be revised and internal working models Mentalization and Attachment Style can be reconfgured (Zilcha et al., 2011). As Holmes Mentalization is the ability to understand hu- (2000) describes, this restructuring of working mod- man action in the context of one’s underlying mental els is like “story-making” and “story-breaking”. The representations (Bateman et al., 2003). The capac- internal world of the adult patient is reassembled in a ity for mentalization is the foundation of a stable way that allows a more coherent narrative of the self structure of the self and is developed through ear- to be formed, as well as the events of one’s life to ly attachment and subsequent social experiences “fall into place” (Sable, 2007). With regard to attach- (Gergely et al., 1996). Disorganized and/or weak ment, it is the discovery of meaning in our personal early attachments can become incorporated into the history that infuences the security of our state of self-structure resulting in the experience of oneself mind, rather than the actual content of this history. and others in this maladaptive, disoriented mode. In Attachment and interpersonal theorists agree that adults, there is an unconscious, active adherence to a therapist’s noncomplementary response to a client’s the preexisting “rules of attachment” based on these attachment tendencies promotes an opportunity for a assumptions. With an unstable sense of self, the in- client’s internal working models (also called “interper- dividual inherently strives to defend their distorted sonal complementary hypothesis”) to be challenged and schematic perceptions of self, others, and rela- and revised (Bernier et al., 2002; Goodman, 2010). tionships against threats that may confict with these By fexibly taking on a contrasting stance to the cli- perceptions, perhaps through aggressive impulses ent’s rigid assumptions, no reinforcement is given to or mental isolation (Bateman et al., 2003). This re- the client’s infexible interpersonal orientation and duced capacity to mentalize can be refected in poor there is an opportunity for the client to explore alter- interpersonal relations, maladaptive and insecure as- native expectations of the self and/or relationships. sumptions about oneself, and emotional volatility. For example, a therapist treating a dismissing patient In psychotherapy, the issues of mentalization can needs to slowly encourage refection on the patient’s be addressed and improved (Bonovitz, 2010). The emotional issues he/she is trying to ignore, rather therapist can help cultivate a patient’s capacity for than allowing these issues to be overlooked (Bernier mentalization by consistently questioning and refect- et al., 2002). On the other hand, a therapist working ing on the internal states within the patient (and with- with a preoccupied patient, who is pouring out his/ in the therapist) characterizing the current moment her emotional issues and is clinging to the therapist, (Bateman et al., 2003). The mutual exploration allows must gradually encourage autonomy (Bernier et al., the therapist to discover links between external and 2002). If the therapist gives in to every demand and internal experiences that seem incomprehensible for need of the preoccupied patient, the individual’s in- the patient (Bateman et al., 2003). This clarifcation al- ternal working model of the self will only become lows the patient to become aware and make sense of more enmeshed with his/her relationships and the previously ambiguous feelings about oneself, others, negative attachment behaviors will be reinforced. and relationships (Bateman et al., 2003). The argu- The security of the therapist’s own attachment ment is that feelings are re-experienced and released system, which will be discussed below, contributes during the psychotherapeutic process as one repro- to his or her capacity to adapt to the needs of the cesses past experiences. This allows for the patient

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to organize a more accurate construction of experi- an insecurely attached individual may feel discomfort ence and restructure the self (Leger, 1998). Conse- with closeness in relationships and/or anxiety in times quently, this new understanding and sense of control of separation (Wallin, 2007). The negative internal over one’s internal states facilitates mentalization. working models of the self and/or other fuel distress due to the insuffcient development of appropriate Internal Working Models of Patients Based On physiologic and affect regulation as a result of poor Attachment Style early caregiving experiences. In these cases, attach- It is critical for the therapist to understand the ment repair must precede introspective exploration. nature of the internal working models each patient brings into treatment. Individuals with a secure attach- Categorization of Attachment Patterns ment style hold assumptions that are both practical In regards to childhood attachment, sever- and benefcial for their internal wellbeing and social al different categorization schemes have been experiences. Their internal working models sustain proposed consisting of different labels and a trust in the goodness and competence of the self numbers of categories. For the sake of simplic- and others, as well as a desire for and a confdence in ity, in this piece, I will focus on the categories pro- relationships (Bordin, 1979; Diener et al., 2011; Levy, posed by Ainsworth (1978) and Main et al (1986). 2005). Individuals with a secure attachment are less Their work yielded four patterns of attachment: se- restricted by internal rule-based patterning, enabling cure, insecure-ambivalent, insecure-avoidant, and dis- them to be fexible in their interpersonal communica- organized (Dolan et al., 1993; Hietanen et al., 2006). tions (Wallin, 2007). This internalized positive inner Children’s attachment styles are highly correlated with working model facilitates a higher tolerance for anxi- similar attachment patterns in adulthood. There are ety, especially in novel experiences, resulting in a great- also children with attachment styles deemed “cannot er freedom to explore the world and a more coherent classify” since a clear pattern of attachment does not integration of experiences (Mallinckrodt et al., 2005). present itself in the assessment. But, for most, place- They have overall better functioning in areas such as ment into one of the four styles of attachments is impulse control, empathy, and marital relations (Levy, possible. A caretaker may be nurturing and responsive, 2005; Main et al., 1986). A more secure attachment promoting the child’s development of a sense of se- is benefcial for the type of mentalization that per- curity and secure attachment (Levy, 2005; Pally, 2001). mits the effcacy of introspection that can disclose On the contrary, inadequate early caregiving experi- and evaluate attachment infuences on one’s relation- ences could hinder processes like attaining the ability ship functioning and affect regulation (Obegi, 2008). to self-regulate, as well as result in unstable attach- In contrast, an insecure attachment style consists ment thoughts and insecure attachment (Sable, 2007). of internal working models that have a negative, am- For adults, the attachment styles are conceptualized biguous, and mistrusting view of the self and others as: secure-autonomous, preoccupied, dismissing, or (Diener, et al., 2011). Inadequate early caregiving ex- unresolved/disorganized (Hietanen et al., 2006). periences encode in the memory attachment interactions that are inconsistent (Sable, 2007). The dissoci- Assessing Attachment Style & The Adult ated representations of attachment, hypothesized by Attachment Interview (AAI) Main as “multiple models” of attachment, are similar to Freud’s ideas regarding the dynamic unconscious. As previously described, an infant’s early attach- Instead of the unlimited access to attachment-related ments to caregivers are internalized forming cogni- information present within secure individuals, those tive-affective structures (Bowlby, 1980) that evolve with “multiple models” are governed by rigidity in into similar models in adulthood and are active in what they are supposed to know and feel rather than one’s current emotional and relational involvements. being able to use the entirety of their experiences The concept of adult attachment styles refers to in- (particularly those that are threatening). Therefore, dividuals’ comfort and position in close relationships,

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their tendency to favor autonomy or dependency, view (ASI) may be a valuable supplement given that as well as their anxiety regarding rejection and in- it concentrates on the aspects and coherence of one’s accessibility in relationships (Ainsworth et al., 1978; narrative, but also addresses the entire range of adult Meyer et al., 2001). For an attachment-informed psy- relationships (Cortina et al., 2003). There are also chotherapist, the initial assessment focuses on the some measures that use a multi-item continuous scale quality of the potential client’s relationships (Cor- (Smith et al., 2009), such as the Experiences in Close tina et al., 2003). A central part of the assessment Relationship Scale (ECRS; Brennan et al., 1998) and will be the history of primary caregivers’ respon- the Adult Attachment Inventory (AAI; Simpson et siveness or inattentiveness, especially noting wheth- al., 1992). These measures evaluate anxiety and avoid- er the client experienced a loss of or abandonment ance, with lower scores on both dimensions indicating by a caregiver, and the subsequent attachment style a more secure attachment pattern (Smith et al., 2009). the client developed (Cortina et al., 2003). Attach- The three insecure attachment styles discussed ment style can usually be adequately assessed with- above are the result of poor and/or inadequate early out the complete implementation of a validated in- attachment relationships. Individuals possessing these strument; however, a tool like the Adult Attachment attachment styles often suffer problems in emotional Interview (AAI) is very useful (Cortina et al., 2003). control and serious psychological distress that con- The Adult Attachment interview (AAI) is the tribute to their anxiety, depression, hostility, and mal- most accepted interview method of assessing adult adaptive patterns in interpersonal relations (Bachelor attachment measures; however, self-report question- et al., 2010). Anderson and Perris (2000) performed naires can also be used to measure attachment patterns two studies to assess the relationship between adult (Eagle, 2006). The AAI, formulated by Mary Main attachment styles and dysfunctional working mod- and her colleagues, involves an hour-long interview els using the AAI, the Attachment Styles Question- in which an adult self-reports behaviors in intimate naire (ASQ), and the Dysfunctional Working Models relationships and narrates experiences in childhood Scale (DWM-S). They found statistically signifcant concerning early relationships with his or her parents correlations supporting their hypotheses that secure (Bernier et al., 2002). This process unveils the per- attachment is negatively associated with dysfunc- son’s “states of mind regarding attachment” (Harris, tional assumption scores and insecure attachment is 2004) and “autobiographical competence” (Holmes, positively associated with dysfunctional assumptions. 1995). Of primary importance, is the coherency of Consequently, individuals with insecure attachments the narrative one relates about childhood experiences have a greater need to piece together experiences and relations. The clinician’s task is to listen to the pa- that have caused the dysfunctional working models tient’s story, try to fnd meaning within it, and uncov- increasing distress and symptomology (Sable, 2007). er the clues in the story that underlie the attachment Cortina and Marrone (2003) present a chart pattern (Holmes, 1995). With treatment, the therapist matching attachment style and type of prior caregiv- and client can work jointly in re-writing the client’s er with the related issues involving the creation of narrative (Holmes, 1995). As the psychotherapeutic a supportive therapeutic alliance and potential solu- process unfolds, change and improvement can be tions. For example, a client who is fearful of rejec- assessed by the cultivation of a more fowing, com- tion is paired with a previous caregiving fgure that is prehensible, and expressive story (Holmes, 1995). consistently rejecting and/or unresponsive to needs It is important to note the AAI’s focus on child- (Cortina et al., 2003). An issue in therapy may be hood omits insight from some relevant relationships, the client’s avoidance of talking about his or her ac- such as those with siblings, marital partners, and co- tual concerns and needs since there is a fear that do- workers (Cortina et al., 2003). The optimal means of ing so will lead to rejection (Cortina et al., 2003). To assessment may be for the clinician to use the AAI address this issue, the therapist must focus on con- with other measures or questions (Cortina et al., veying the non-judgmental context of therapy and 2003). A measure like the Attachment Style Inter- the therapeutic relationship (Cortina et al., 2003).

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The table provided by Cortina & Marrone (2003) apeutic process, especially with regard to the creation incorporates the augmented classifcation of attach- of the working alliance (or client-therapist alliance) ment styles used by Bifulco and colleagues (2002) (Hietanen et al., 2006; Smith et al., 2009). Greenson as a guide to help the development of the alliance. (1967) was the frst to use the term “working alliance” However, a plausible concern for using attachment (Diener et al., 2011; Horvath et al., 1991), which he measures in a clinical setting is: if the patient is clas- defned as a “rational relationship between patient sifed as having a certain attachment style, is there a and analyst” (p. 46). Considering the heavy infuence greater likelihood therapists will misinterpret experi- of the attachment styles of both the therapist and ences with a patient and establish their views based of the patient on the formation of the alliance, Bor- on the patient’s initial attachment classifcation? din (1979) views the alliance as “dyadic and mutual Daly and Mallinckrodt (2009) interviewed expe- with the therapist and client as active co-constructors, rienced therapists about approaches they found ef- constantly negotiating and renegotiating the alliance fective for clients with particular attachment styles. in order for successful work to take place” (Bordin, Therapists reported the importance of gradually 1979; Smith et al., 2009). When it comes to the actu- increasing the therapeutic distance with anxiously al “alliance”, Bordin (1979) hypothesized the alliance attached clients (Daly et al., 2009). Conversely, the to consist of three facets: the goal, the task, and the therapists suggested a gradual decrease in therapeutic bond (Diener et al., 2011; Hietanen et al., 2006; Smith distance for avoidant patients (Daly et al., 2009). In et al, 2009). The goal and the task involve the cogni- addition to guiding the therapist’s approach for the tive elements of the alliance, specifcally the agree- patient, awareness of the patient’s attachment history ment on the general objectives of treatment and the prepares the therapist for the types of transference particular actions that will be employed to achieve experiences that may occur, as well as improves the the set goals (Bordin, 1979; Hietanen et al., 2006). therapist’s understanding of his or her own possi- The bond, the emotional and relational component, ble countertransference reactions (Shilkret, 2005). involves all the affective experiences that enables cli- There are different manifestations of transference ent to develop an attachment to the therapist, such that patients can display, which may vary through- as the client’s feelings of trust and empathy (Bordin, out treatment (Goodman, 2010). Interestingly, Freud 1979; Hietanen et al., 2006). It is the attachment to (1912, 1913) discussed the dynamic of transference the therapist that allows the client to participate in involved in psychotherapy: the unconscious negative the tasks and achieve the goals (Smith et al., 2009). component, the unconscious positive component, The opportunity for therapeutic change occurs with and the conscious “unobjectionable” component the therapist and client attending to and repairing ob- (Goodman, 2010). The frst two serve as opposi- stacles resulting from a disagreement about one or tions to treatment, while the latter represents feel- more of the three components (Smith et al., 2009). ings of value towards treatment and facilitates suc- Since times of danger or distress both activate attach- cess in treatment (Goodman, 2010). Moreover, he ment systems and often bring clients to therapy, re- identifed the patient’s attachment to the therapist searchers have come to link the concept of the ther- as a requirement for the occurrence of unobjec- apeutic alliance with attachment theory (Farber et al., tionable transference, which facilitates the devel- 1995; Harris, 2004; Sable, 2007; Smith et al., 2009). opment of the working alliance (Goodman, 2010). Research has found that a stronger alliance is associated with less distress in psychotherapy as treatment The “Working Alliance” in Attachment-Focused progresses (Sauer, 2010; Smith et al., 2009). In con- Therapy with Adults trast, the failure to develop an alliance can bring about a premature termination of therapy (Harris, 2004). Attachment theory and research shed enormous Horvath and Greenberg (1986) developed the Work- light on both the client’s and therapist’s internal ing Alliance Inventory (WAI) to measure this work- working models infuencing the progression of ther- ing alliance, which includes the three subscales (task,

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goal, and bond) (Goodman, 2010; Smith et al., 2009). tions, feelings, and behaviors (Eagle et al., 2009; Ma- honey, 1990, paraphrased from Leger, 1998; Sable, The Therapist As A Secure Base 2007). This transformation towards a stable, coherent The therapeutic relationship is more than a bond; self-representation is not possible in psychotherapy it is also an attachment (Obegi, 2008; Zilcha et al., without the therapist’s fundamental role as a “secure 2011). The relationship incorporates characteristics base” (Bowlby, 1980; Eagle et al., 2009; Farber et al., of child-caregiver relationships, such as the reassuring 1995). The empathy of the therapist, the security of presence of the therapist and the possibility for emo- the client-therapist relationship, and the safe intimate tion regulation ( Goodman, 2010; Meyer et al, 2001). space are needed for the patient to obtain the free- First, the child must come to see the caregiver as a dom to think and feel without the fear that his or her reliable attachment fgure that he or she can turn to unstable or fragile self will be threatened or attacked. if threatened or distressed, making them a safe haven In addition to the therapist’s function as a secure (Eagle, 2006). Through experiences of an encouraging base within the therapeutic setting, the patient can and available attachment fgure, the child then can use utilize the representations of the therapist developed the caregiver as a secure base that provides the com- through attachment, even after the termination of fort and confdence a child needs to be motivated to therapy, during times of stress in order to gain that explore the world (Ainsworth et al., 1978; ,1980; Ea- sense of comfort and competence that allowed for gle, 2006; Farber et al., 1995; Lamagna, in press; Levy, problem solving during treatment, as well as to ex- 2005; Lipton & Fosha, 2011; Mikulincer et al., 2007). plore new opportunities and relationships (Farber et Similar to the caregiver-infant relationship, Bowl- al., 1995). The evocation of the therapist’s internal by (1980) proposes the therapist serve as a secure working model (discussed above during emotional base from which the patient can safely explore dif- and/or interpersonal strain can even help the indi- fcult psychological matters relating to both internal vidual regulate affect and change the way he or she and external factors (Dozier et al., 2004; Eagle et al., approaches the stressful situation (Eagle et al., 2009; 2009; Farber et al., 1995; Goodman, 2010; Holmes, Obegi, 2008). The new strategies for dealing with 1995; Meyer et al., 2001; Schauenburg et al., 2010; stress and relationships refect a positive transfor- Zilcha et al., 2011). As a receptive fgure, the therapist mation in the client’s internal working models and accepts the client’s feelings, offers emotional avail- attachment security (Eagle et al., 2009). The client’s ability, and provides regulated affect, which allows increased capacity for refective functioning per- for the development of attachment (Malinckrodt et mits the construction of a more coherent narrative, al., 1995; Mikulincer et al., 2007; Sable, 2007). The which is less ambiguous and conficting (Eagle et al., positive attachment relationship with the therapist 2009). Lipton and Fosha (2011) propose, “through facilitates the client’s confdence in his or her own meta-therapeutic processing, or metaprocessing for abilities and in the capacity to have fulflling relation- short, the secure attachment relationship between al experiences (Sable, 2007). Therapists’ empathetic patient and therapist becomes the vehicle through presence combined with the mastery they project which a patient’s right-brain experiencing of psycho- embeds a base that a patient feels comfortable using therapy is integrated with her left-brain, conscious, to venture into diffcult territories (Holmes, 2000). verbal knowing that a therapeutic experience has just By refecting on past life experiences and early occurred” (p. 271). The resulting clarity in one’s nar- attachment relationships with the help and support rative and the improvement of refective functioning of therapists, patients can give meaning to past ex- foster a sense of security and stability in the view periences and explore the infuence they had and/or of not only oneself, but also in the view of others. have on their distress and functioning (Sable, 2007). The availability of the therapist during exploration The Alliance As A Predictor of Therapeutic facilitates the change needed for the client to explore Outcome and make modifcations to his or her current cogni- Research has indicated that the quality of the

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early working alliance and the nature of the thera- 2009). Dolan et al. (1993) also propose that perhaps pist as a secure base is crucial to the therapeutic out- more research should be done on whether therapists’ come (Diener et al., 2011; Harris, 2004; Horvath et modify their interpersonal stance and intervention al., 1991; Meyer et al., 2001; Mikulincer et al, 2007; strategies based on the client’s attachment style and Sauer et al., 2010; Schauenburg et al., 2010; Smith et how the therapist perceives the therapeutic alliance. al., 2009). Byrd et al. (2010) studied the impact of Studies investigating the working alliance rela- the working alliance on the patient’s attachment style tionship have primarily focused on clients’ individual during treatment, as well as the impact of the attach- pretreatment characteristics, such as motivation and ment style on the psychotherapeutic process. Results sociability (Horvath et al., 1986; Smith et al., 2009). showed that two attachment dimensions (Comfort Clients’ internal working models determine their per- with Closeness and Comfort Depending on Others) ceptions of the therapist and the client-therapist re- were positively related to the alliance and treatment lationship (Bowlby, 1980; Dozier et al., 2004; Eames outcome. Additionally, the alliance infuenced the et al., 2000; Smith et al., 2009; Zilcha et al., 2011). dimension Comfort with Closeness, which, in turn, Especially when working with insecurely attached promoted more successful therapeutic outcome. patients, knowledge of patients’ attachment histo- It has also been proposed that therapists’ per- ries can provide the therapist with insight that can ceptions of the therapeutic alliance depend on the help them predict potential ruptures in the alliance; attachment style of the client, while the client’s per- therefore, they can be proactive in their methods for ception of the therapeutic alliance was not related to intervening (Diener et al, 2011; Shorey et al., 2006). attachment style (Dolan et al., 1993; Horvath et al., Recognizing the signifcance of attachment experi- 1986). Therapists reported a stronger therapeutic al- ences in the therapeutic relationship, Mallinckrodt, liance with secure patients and a weaker alliance with Gantt, and Coble (1995) created the Client Attach- patients that had a more avoidant attachment (Dolan ment to Therapist Scale (CATS) (Sauer et al., 2010). et al., 1993). A meta-analytic review investigated past The measure contains three subscales similar to at- research exploring the relationship between client attachment style classifcations: Secure, Avoidant-Fear- tachment and the therapeutic alliance, which consist ful, and Preoccupied-Merger (Sauer et al., 2010). A of two categories of client attachment, clients’ glob- study investigating the relationship between attach- al attachment patterns and clients’ specifc attachment and the early therapeutic alliance reported that ment pattern to their therapist (Smith et al., 2009). preoccupied attachment in patients predicted more The theoretical literature indicates that with regard frequency in ruptures, whereas dismissing attach- to patients’ global attachment, clients’ secure attachment was associated with fewer ruptures (Eames et ment yields a stronger therapeutic alliance (Diener et al., 2000). Attachment theory can facilitate the build- al., 2011; Mikulincer et al., 2007; Smith et al, 2009). ing and maintenance of the therapeutic alliance that Similarly, those who perceive themselves as secure- endows a client with a perception of safety and a ly attached to their therapist develop stronger ther- motivation for deep exploration, and, thus, the pos- apeutic alliances (Smith et al., 2009). On the other sibility for a positive therapeutic outcome and a re- hand, clients with an avoidant-fearful attachment duction in symptomology (Mallinckrodt et al., 2005). pattern experience a less positive therapeutic alliance (Smith et al., 2009) Comparing the two catego- The Patient’s Attachment Style ries, evidence supports that the client’s attachment to therapist has a greater impact on the therapeutic The Secure Patient alliance than the client’s global attachment (Smith During the AAI, adults with secure attachments et al., 2009). Perhaps measuring clients’ specifc at- convey coherent narratives that integrate past experi- tachment may be more valuable than measuring cli- ences in a relatively balanced manner (Mallinckrodt et ents’ global attachment when interested in predicting al., 2005). These individuals most likely do not have the quality of the therapeutic alliance (Smith et al., picture-perfect childhoods, yet they can understand

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and refect on past early attachment relationships, about emotional dysregulation and an overwhelming whether they were positive or negative (Sable, 2007). energy that blinds the individual from forming rea- Lipton and Fosha (2011) suggest, “Several decades of sonable and objective perceptions (Badenoch, 2008). research on the moment-to-moment (and even milli- Badenoch (2008) terms the preoccupied individual’s second-to-millisecond) interactions between moth- internal world an “emotional jungle” (p. 70). With ers and their babies tells us that reiterative, ongoing regards to relating with others, the mental models cycles of attunement, disruption and repair in the guiding them lead them to expect they will have jag- context of emotional experiencing are the essential ged and unreliable relationships (Badenoch, 2008). building blocks of secure attachment”(p. 258; Bee- They exaggerate their personal distress and have be et al., 2002). This type of security in attachment an overwhelming need for the support and closeness is necessary for the self-refective mentalization that of others (Bernier et al., 2002; Dozier et al., 1995; supports introspection and metacognition (Mallinck- Main et al., 1998). Their state of mind typically con- rodt et al., 2005). With the ability to examine cur- sists of enmeshment in past and current relation- rent and past experiences in a constructive fashion, ships, as well as confused feelings, possibly anger an adult can develop a more balanced approach and or fear, toward relationships (Atkinson et al., 2004; appraisal of relationships, as well as better strategies Badenoch, 2008; Bernier et al., 2002). An AAI nar- for resolving thoughts, memories, and feelings that rative would consist of continuous interchanges of are related to distress (Sable, 2007). Thus, attachment past and present experiences that are tangled together security strongly infuences functioning in interper- in a confusing disintegrated web, representing a poor sonal relations, the capacity for affect regulation, and sense of self (Badenoch, 2008). Their narratives may psychopathology in adulthood (Atkinson et al., 2004 be extremely lengthy, with the clients becoming so Obegi, 2008). A person assessed as having a secure caught up in their memories that it seems as if they attachment will be more willing to self-disclose in- are reliving past experiences (Atkinson et al., 2004). formation about him- or herself in psychotherapy At the onset of therapy, preoccupied clients are (Atkinson et al., 2004; Mikulincer et al., 2007). There- more likely to have high anxiety and distress, and they fore, the formation of an emotional bond between often ruminate about what the therapist and others therapist and patient would most likely be an easier may have said (Atkinson et al., 2004; Mikulincer et al., and quicker process than with those patients lacking a 2007; Shilkret, 2005; Smith et al., 2009). They are of- secure attachment (Bordin, 1979; Smith et al., 2009). ten concerned with the availability of the therapist and want to be emotionally and physically close (Mikulinc- The Preoccupied Patient er et al., 2007; Smith et al., 2009). The chaotic swap- Among those assessed to have an attachment ping, lack of coherency, and anxiety the patient brings style that is not defned by a sense of security, there is to therapy can even make the clinician a bit anxious greater likelihood for psychopathology, dysfunction, (Badenoch, 2008). In this case, it is important that the and distress. For preoccupied individuals, intense therapist be mindful and remain calm, as simply the anxiety, hyperactivation, and defense mechanisms are presence of the therapist’s calmness can promote the maintained in order to combat feelings of insecurity patterning of emotion regulation (Badenoch, 2008). and psychological distress that has resulted from insecurity in early attachment experiences (Bachelor et The Dismissing Patient al., 2010; Smith et al., 2009). Most likely, as children Dismissing individuals, by contrast, tend to their caregivers were unpredictable leading them to minimize the signifcance of early attachments and develop neuroceptions of potential danger, as well believe relationships are relatively unimportant (At- as create contradictory internal representations of kinson et al., 2004; Badenoch, 2008; Bernier et al., the caregiver (Badenoch, 2008). The disintegration 2002; Mikulincer et al., 2007; Muller, 2009; Zilcha et characterizing their childhood experiences results in al., 2011). These patients have diffculty engaging in disruptions in the brain’s neural networks, bringing discussion regarding the inadequacy of their early at-

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tachment relationships, and, thus deny their feelings The Unresolved Patient about these issues (Atkinson et al., 2004; Mikulincer Similarly, those with unresolved attachment styles et al., 2007; Muller, 2009; Zilcha et al., 2011). Even often lack recollections of important experiences re- traumatic events will be minimized into an occur- lating to attachment in childhood (Dozier et al., 2004). rence that is more socially accepted (Muller, 2009). They are so overwhelmed by the loss or trauma they Applying the role of imagination proposed by Bono- experienced that they may have a lapse in reasoning vitz (2012), these individuals may overly use fanta- (e.g., refusing to believe a person is dead), discourse, sy to avoid facing reality, resulting in rigidity in life and behavior (Dozier et al., 2004). These individuals and trouble in interpersonal relations (Bonovitz, are even more disorganized in their cognitions and 2012). Due to their insistence on self-reliance and behaviors due to the inability to resolve early trau- separateness, they have diffculty forming bonds and mas in attachment (Bernier et al., 2002). Their inner they reject or deny attachment needs (Bernier et al., worlds are fragmented, consisting of both chaos and 2002; Dozier, 2004; Eagle, 2006; Main et al., 1998; rigidity (Badenoch, 2008). The disorganization that Mikulincer et al., 2007; Muller, 2009, 2007; Shorey characterizes the unresolved pattern of attachment et al., 2006; Smith et al., 2009; Zilcha et al., 2011). is demonstrated when these patients discuss ear- The discourse of dismissing patients’ narratives ly attachment experiences and current relationships may be fuent, yet seems to be very superfcial and (Shilkret, 2005). Not surprisingly, individuals with un- lack details (Badenoch, 2008; Bernier et al., 2002; resolved attachments are more likely than others to Dozier et al., 2004). There is either dissociation or be found in a psychiatric setting (Dozier et al., 2004). absence of many aspects of early attachment expe- While relaying their narratives, unresolved-at- riences and emotional numbness as well (Bernier et tached patients’ speech may appear disorganized in, al., 2002; Muller, 2009). Badenoch (2008) describes for example, the use of incorrect tenses (e.g., using the mental model of a dismissing patient as an “emo- the present tense when speaking about the past), long tional desert” (p. 68). The patient may describe their pauses, and inability to fnd one’s words (Badenoch, parents as “nice” or the relationship as “good” (Bad- 2008). During the course of therapy, they may pres- enoch, 2008). When listening to these narratives, client as one of the other attachment styles at different nicians may struggle to grasp the internal model and times, as they sporadically vary in the symptoms they community directing the patient’s mind (Badenoch, are suffering from and their affective states (Shilkret, 2008). Patients may convey cues that the therapist 2005). Lamagna (in press) describes this common should not probe discussion on a certain topic or in- manifestation as “come close/stay away” messages trude in areas of their life that they insist are not trou- (p.8). The patient’s lack of coherency in discourse bling (Dozier et al., 2004). When treating a dismiss- and behavior can cause a therapist to feel unstable ing patient, there may be a challenge in creating an and confused (Badenoch, 2008). Therapy with pa- interpersonal connection, especially since dismissing tients characterized by the unresolved attachment individuals often lack the ability to read others’ sig- style is flled with confusion; therefore, the therapist nals (Badenoch, 2008). A particular obstacle to a ther- must strive to maintain calmness and clarity (Shilkret, apist’s relationship with a dismissing client is “mutual 2005). Additionally, it is important to mention that avoidance” (Muller, 2009). The patient’s ambiguous these patients often come to therapy feeling ashamed feelings toward a trauma or attachment relationship about hurting those they loved with their unmanage- lead the therapist to question how to react; therefore, able behaviors (Badenoch, 2008). For this reason, the therapist surrenders to the patient’s pull to avoid the beginning of therapy must consist of the ther- the topic (Bernier et al., 2002; Muller, 2009). Muller (2009) suggests, “The challenge in treatment, then, is 1 Some theorists hold that those with unresolved attachments always in helping such patients fnd a way to tell a story too can be diagnosed with an additional attachment pattern simultaneously (Main & Solomon, 1986; Badenoch, 2008). For example, painful to speak, but too compelling to ignore” (pp.79). a patient may have a secure attachment to his father, while having an unresolved attachment with his mother (Badenoch, 2008).

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apist making a purposeful effort to provide patients apist, causing him or her to involuntarily react with- with a sense of empathy, as well as emphasize the out thinking (Pally, 2001). All of these occurrences patients’ ability to change the dissociated mental can hinder the therapist’s capacity to be empathetic, models that led to regretful actions (Badenoch, 2008). the quality of his/her technical skills, and the capacity for affect attunement (Mallinckrodt, 2010). These The Therapist’s Attachment Style elements have an infuence on the treatment condi- tions and outcome, as well as the therapeutic rela- Of tantamount importance to the therapeutic en- tionship (Meyer et al., 2001; Pally, 2001; Sable, 2007). deavor is the therapist’s attachment style (Meyer et al., 2001). Just like any other individual, the therapist pos- Securely- Attached Therapists sesses his or her own internal working models and at- Therapists who are securely attached typical- tachment patterns (Bennett, 2008). In order for treat- ly exhibit behaviors consistent with this attachment ment to be effcacious, the therapist must be aware style, such as warmth and trustworthiness, which of his or her attachment style due to its large impact are benefcial for developing relationships (Obegi, on one’s interpersonal competencies and disposition, 2008). These secure attachment representations pro- and, thus, the client’s experience of the therapist and vide the therapist with greater fexibility, stability, and vice versa (Atkinson et al., 2004; Bennett, 2008; Wal- autonomy when in diffcult interpersonal situations, lin, 2007). The internal working models of therapists such as an uncomfortable fght with a patient and affect their patterns of self-protection, their ability to the inevitable ruptures in the therapeutic relation- be self-refective, their capacity for caregiving (em- ship (Lopez & Brennan, 2000; Meyer, 2001). Instead pathy), their proclivity for empathic understanding of acting on one’s own attachment related fears and and their range of affect regulation (Bennett, 2008). needs, the therapist can adapt his or her behaviors Cortina and Marrone (2003) suggest four import- to suit the needs of the patient involved in the inter- ant factors infuencing the quality of the therapist’s personal diffculty, affording better care for the pa- empathetic understanding, which include: his/her tient (Cortina et al., 2003; Schauenburg et al., 2010). own early attachment history, his/her own experienc- The study by Schauenburg et al (2010) focused on es as an analysand (client), his/her own experiences the infuence of therapists’ attachment representa- in clinical supervision, and his/her theoretical frame- tions on the alliance and confrmed the benefcial work or biases. As a clinician, one needs to mental- effect of therapists’ attachment security on the work- ize during sessions with patients in order to separate ing alliance with interpersonally distressed patients. his or her feelings and experiences from those of the patient, while simultaneously recognizing the mental Insecurely- Attached Therapists states of the patient (Bateman et al., 2003). When in- Conversely, therapists with an insecure attach- teractions provoke unconscious conficts and wishes ment style, such as dismissing or preoccupied, may in the therapist, it is possible for defense mechanisms have diffculty when it comes to working through and to become mobilized and uncomfortable counter- dealing with ruptures given the anxiety and fear of re- transference to occur (Bateman et al., 2003). The jection that constitute these attachment styles (Meyer phenomenon of countertransference involves the et al., 2001). Their insecure attachment needs may changes in the therapist’s state of mind and automat- also lead to substandard intervention strategies and ic verbal/nonverbal behaviors that the patient picks an inability to be self-refective (Bennett, 2008). Due up, causing either the exacerbation or alleviation of to the lack of refection in insecurely attached ther- anxiety and other symptoms (Pally, 2001). Counter- apists, they may struggle with the regulation of their transference may occur due to the therapist’s need to own affect; therefore, they lack the ability to facili- be guarded from the patient’s transference, resulting tate affect regulation in the patient, a critical healing in a distancing in the relationship; or there can be an element in the therapeutic process (Bennett, 2008). activation of automatic internal responses in the ther- Given that therapist attachment style predicts aspects

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of countertransference, therapists with dismissive at- are prone to using defensive deactivation (active in- tachment may be more distant with diffcult patients hibition of attachment-related material). Therapists and situations, as well as have more antagonistic coun- need to challenge the client’s defensive strategy be- tertransference reactions to patients (Bennett, 2008). cause this coping mechanism will only save the pa- Those with preoccupied attachment style might fear tient from distress for a short time and will eventually they are inadequate and struggle to separate their own fail (Muller, 2009). According to Cortina & Marrone anxieties and emotions from those of the patient (2003), disconfrming the internal working models (Bateman et al., 2003; Bennett, 2008). These fndings of dismissing (avoidant) patients’ is easier than doing suggest that the therapist’s attachment style interacts the same for preoccupied patients. Whereas avoid- with the client’s attachment style to determine trans- ant individuals’ primary attachment fgures were ference and countertransferences, the interpersonal unresponsive, preoccupied individuals experienced experience, and, most importantly, the building and inconsistency in their primary attachments (Cortina strength of therapeutic relationship (Bennett, 2008). et al., 2003; Smith et al., 2009). As discussed before, the capacity of the therapist to carry out this adap- Interaction Of Therapist and Client Attachment tation depends on his or her attachment style, with Styles securely-attached therapists being the most adaptable Taking into account the importance of the at- (Bernier et al., 2002). The therapist’s resistance to tachment style of both clinicians and patients, it is naturally respond to the patient’s attachment tenden- not surprising that the interaction between the two cies in a conforming manner can facilitate emotion- styles weighs heavily on the therapeutic process. al change and growth within the patient (a correc- Some research has indicated the advantageous effect tive experience) (Bernier et al., 2002; Bowlby, 1980). of similarities between the therapist and client re- For example, a dismissive client may avoid spe- garding attitudes, personal beliefs and values, expec- cifc topics containing deep emotional content. In- tations toward counseling, and self-concept (Bernier stead of courteously following the patient’s attempt et al., 2002). This would lead one to think that simi- to focus on nonthreatening issues, the therapist needs larity in attachment styles would be optimal for psy- to carefully challenge the client’s strategies and pro- chotherapy (Bernier et al., 2002). However, interper- mote the gradual exploration of the more intimate sonal researchers and theorists suggest the presence issues the client tries to shroud with superfcial con- of both complementary and non-complementary versation (Bernier et al., 2002; Dozier et al., 1998). exchanges is superior to the employment of simply On the other hand, excessively emotional or preoccu- complementary or non-complementary stance (Ber- pied patients may require interventions encouraging nier et al., 2002). Although interpersonal theorists the control of emotions and autonomy (Bernier et believe in the need for complementary exchanges, al., 2002; Meyer et al., 2001). Hence, corrective ex- they are in agreement with attachment theorists and periences are facilitated by matching therapist with studies proposing the importance of dissimilarities in patient based on dissimilar deactivating (avoidance) the interpersonal facets of client and therapist, and versus hyperactivating (clinging) dimensions of at- the notion that noncomplementary attachment styles tachment (Bernier et al., 2002; Tyrell et al., 1999). are optimal for treatment (Bernier et al., 2002). If One study reported by Tyrell et al (1999) found that the therapist reinforces the client’s rigid expectations preoccupied therapists formed the strongest alliance and/or replicates the aspects of the client’s poor with dismissing patients and vice versa (Bernier et al., early attachment experiences in therapy, it can pos- 2002). Undoubtedly, the interaction of attachment sible re-traumatize the patient (Cortina et al., 2003). styles in psychotherapy is impactful on the transfor- Bowlby (1980) suggests that the therapist fex- mation of patient’s maladaptive thoughts and behav- ibly adopt a contrasting stance that will challenge iors and the formation of the therapeutic alliance. the client’s beliefs and rigid expectations about rela- In addition to the impact of the therapist’s at- tionships (Bernier et al., 2002). Dismissing patients tachment style, the style of interpretation a therapist

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uses also has implications in psychotherapy (Cortina others treat them, and, thus, affects their likelihood et al., 2003). Even in the context of a strong ther- to suffer from psychopathology (Carlson, 1998 para- apeutic relationship, certain types of interpretations phrased from Snyder & Shorey, 2006; Harris, 2004). can have a negative infuence, such as decontextual- Undoubtedly, it is the internalization of these ization and double binding (Cortina et al., 2003). De- negative early experiences that generate negative in- contextualization refers to placing too much empha- ternal working models (Harris, 2004; Levy, 2000; Wal- sis on the patients’ unconscious feelings and internal lin, 2007). With their strong impact on how one car- mechanisms (Cortina et al., 2003). Consequently, the ries out his or her life, internal working models may therapist undervalues the patients’ subjective feel- give the impression of being irreversible and resolute ings and the effects of the external world (Cortina (Wallin, 2007). Although they have a strong infuence et al., 2003). The other counterproductive interpre- on personality and interpersonal interactions, internal tation, double binding, for example occurs when the working models and one’s attachment state of mind therapist unintentionally instigates a feeling in the are open to modifcations by means of new experi- patient (e.g., makes the patient feel guilty) and then ences and relationships, with psychotherapy being a interprets that the patient possesses a guilt-ridden in- useful modality for positive transformation (Berni- ternal world (Cortina et al., 2003). Using attachment er et al., 2002; Wallin, 2007). Individuals with mal- theory as a guide, the issues of decontextualization adaptive attachment styles may have impairments in and double binding are less likely to occur in the critical psychological processes; such as intersubjec- psychotherapeutic process given the theory’s strong tive relatedness, affect regulation, and mentalization emphasis on the external world’s role in develop- (Bateman et al., 2003). Such dysfunctions can expose ment (Cortina et al., 2003). By taking into account an individual to psychological, physical, and/or social the internal and external worlds of patients, the pa- distress. Key goals of psychotherapeutic treatment tient is less likely to feel he or she is being blamed, using attachment theory involve aiding the patient in: which would impair progress in psychotherapy. identifying unresolved emotions and appropriately expressing affect, developing stable internal repre- Conclusion and Summary sentations of self and others, constructing a secure and coherent sense of self, and acquiring interper- Attachment theory describes the instinctive sonal characteristics that promote the potential for style of individuals seeking proximity or protection positive relationships (Bateman et al., 2003; Holmes, when feeling threatened. Further, it suggests ways 1995). Internal working models can be revised as in which attachment behavior is affected by envi- dysfunctional representations are challenged, refect- ronmental factors (Bowlby, 1980; Sable, 2007). Re- ed on, and transformed (McCluskey, 1999; Zilcha et search in attachment theory following John Bowlby al., 2011). Bowlby (1980) asserted that clients must has given clinicians a compelling reason to explore comprehend how their working models cause their the actual events and relationships in a patient’s early unhealthy thoughts and behaviors in order for these development, as well as the patient’s distinct interpre- models to be revised (Zilcha et al., 2011). The reorga- tations and representations of experiences (Eagle et nization of these infexible internal working models al., 2009). Early adverse experiences with attachment and the therapeutic relationship allows for psycholog- internalized by the receptive infant can impede the ical processes, like affect-regulation, to be established, development of psychological structures that favor as well as new realistic views of oneself and others to resilience; therefore, the infant’s vulnerability to the be formed (Eagle et al., 2009; McCluskey et al., 1999). emergence of psychopathology is heightened (Sable, Attachment-informed psychotherapy has its ad- 2007). It is suggested that, although an individual’s vantages since it not only focuses on the history of attachment style in infancy may be different from that early attachment experiences that led to the maladap- of adulthood, a child’s internal working model strong- tive attachment behaviors of the patient in treatment, ly infuences subsequent behavior, affects the way but also gives the therapist guidance in what approach

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to employ for a particular patient, illuminating an op- References timal trajectory of treatment (Dolan et al., 1993; Har- ris, 2004). With knowledge of a patient’s attachment Ainsworth, M.D. (1985). Patterns of attachment. style, the therapist can be sensitive and adaptive to the Clinical Psychologist, 38(2), 27–29. patient’s needs, increasing and accelerating the chance Ainsworth, M.D., Blehar, M.C., Waters, E. & Wall, S. for exploration and benefcial change to occur (Eagle (1978). Patterns of attachment: A psychological et al., 2009). The therapist’s consistent understand- study of the Strange Situation. Oxford, England: ing from the start can enhance the experience of the Lawrence Erlbaum. xviii 391 pp. therapist as a secure base and strengthen the bond Anderson, P. & Perris, C. (2000), Attachment styles between the therapist and client, allowing the client and dysfunctional assumptions in adults. Clinical to increase his or her exploration, and resolve the is- Psychology & Psychotherapy, 7, 47–53. sues involved (Eagle et al., 2009). In addition to the Atkinson, L,, & Goldberg, S., (2004). Attachment is- therapist’s support in confronting negative feelings sues in psychopathology and intervention. Mah- and forming new models, the patient’s experience of wah, NJ: Lawrence Erlbaum Associates, Inc., a trustworthy and reliable other (the therapist) is a Publishers. healing element in itself (Eagle et al., 2009; Obegi, Bachelor, A; Meunier, G; Laverdiér, O. & Mache, D. 2008). There is accumulating agreement that the qual- (2010). Client attachment to therapist: Relation ity of the therapeutic alliance is one of the strongest to client personality and symptomatology, and predictors of psychotherapeutic outcome (Harris, their contributions to the therapeutic alliance. 2004; Horvath et al., 1991; Cortina & Marrone, 2003). Psychotherapy Theory, Research, Practice, Train- Some have argued that attachment theory isn’t ing. 47(4), 454–468. applicable to the practice of psychotherapy (Farber Badenoch, B. (2008). Being a Brain-Wise Therapist: et al., 1995). Hamilton (1987) believed attachment is A Practical Guide to Interpersonal Neurobiolo- a “background concept,” and “is all too palpable; we gy. New York, NY: W.W. Norton & Company. are surrounded by it; we can observe it; and yet, from Bateman, A., & Fonagy, P. (2003). The development a clinical point of view, we cannot use it directly.” of an attachment-based treatment program for (p. 69). The relationship between attachment theory borderline personality disorder. Bulletin of the and psychotherapy may not now boast enough em- Menninger Clinic, 67(3), 187-211. pirical research for an explicit “attachment therapy” Beebe, B. & Lachmann, F. M. (2002). Infant research for adults, yet there continues to be growing evidence and adult treatment: Co-constructing interac- and innovative interventions supporting the bene- tions. Hillsdale, NJ: Analytic Press. fts of applying attachment theory and research to Bennett, S.C. (2008). The interface of attachment, the psychotherapeutic process (Eagle et al., 2009). transference, and countertransference: Impli- As more studies are undertaken, the importance of cations for the clinical supervisory relationship. attachment theory and its applicability to practice Smith College Studies in Social Work, 78(2-3). becomes better understood. Evidence suggests that Bernier, A., & Dozier, M. (2002). The client-coun- attachment theory can enhance both the therapist’s selor match and the corrective emotional expe- and the adult patient’s awareness of their roles in the rience: Evidence from interpersonal and attach- psychotherapeutic process and therapeutic alliance. ment research. Psychotherapy: Theory, Research, Additionally, attachment style it is a strong predic- Practice, Training, 39(1), 32-43. tor of outcome for psychotherapy. Taken together, Bonovitz, C. (2012). Disorganized attachment and the strengths of attachment theory suggest prom- the use of fantasy: An interpersonal/develop- ising new directions for psychotherapy with adults. mental perspective. Psychoanalytic Psychology. Bordin, E. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psycho- therapy: Theory, Research, and Practice, 16, 252

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