Addiction and Attachment Brief History of Attachment Theory

10/7/2019

Addiction and Attachment

Julia Murtha, MA, LADC, MHP Planting Seeds Recovery Richfield, MN

“People with insecure attachment look to drugs and alcohol to avoid the anxiety and loneliness of not being able to consistently connect with others.”

(Gabre Mate)

Brief History of Attachment Theory

1 10/7/2019

John Bowlby Developed Attachment Theory

The 4 Basic Attachment Needs of Human Beings • Monitor and maintain emotional and physical closeness with our beloved • Reach out for this person when we are unsure, upset, or feeling down • Miss this person when we are apart • Depend on this person to be there for us when we go out into the world and explore

Mary Ainsworth

• Student of John Bowlby • Developed the idea of attachment styles • Created The Strange Situation experiment • Explored the connection between caregiver and infant

Mary Main

• Studied the intergenerational transmission of attachment • Explored how the caregiver attachment style directly influenced the child • Developed the Adult Attachment Interview (AAI) which was able to predict the response of the child in the Stranger Situation experiment

2 10/7/2019

Cindy Hazan and Phillip Shaver

• Applied Attachment Theory to adult relationships • Studied how a secure attachment in children allows for balance of intimacy and healthy independence in adult relationships

Secure Base • Caregiver acts as a secure base so the child can freely explore their inner and outer worlds. • Caregiver is emotionally available, comforting, able regulate affect, and consistent in response.

Safe Haven Caregiver provides support, protection and comfort in times of distress.

“To remain within easy access of a familiar individual known to be willing and able to come to our aid in an emergency is clearly a good insurance policy—whatever our age.” (John Bowlby)

3 10/7/2019

VIDEO: Still Face Experiment by Dr. Edward Tronick

Attachment Styles

(Momentous Institute, 2019)

What causes Insecure Attachment? • postpartum depression/anxiety in • insecure attachment style in mother caregiver • birth trauma • inadequate support • financial strain (lack of • drug/alcohol use by caregiver food/housing/basic needs) • abuse (physical, emotional, sexual) • relationship conflict • neglect • too many children • traumatic events • ill sibling • loss of a caregiver (death, adoption, • medical condition in caregiver foster care) • untreated mental health in caregiver

4 10/7/2019

Attachment and Addiction

Insecure Attachment leaves people feeling deeply isolated, emotionally disconnected, confused about how they fit into their community, and fearful of not getting their basic needs met.

These are ALL elements of the addiction process.

Healing insecure attachment allows the client to find comfort in people, not drugs.

Whenever people are frightened, fatigued, or sick they show attachment behaviors aimed to elicit care‐giving behaviors in others. The type of care‐giving offered is dependent on the attachment styles of both the distressed person and the

“caregiver”. (Bowlby, 1988)

5 10/7/2019

Attachment Styles in Treatment How does each attachment style show up in the therapeutic relationship?

Shifting the Focus of Treatment

Focusing on building secure attachment is the primary focus of treatment. It makes everything else possible.

Research indicates that an insecure attachment style can shift to a more secure attachment style in the treatment process. This is considered treatment success.

Secure Attachment • More open to exploring their surroundings and relationships • Collaborative, compliant, committed, and proactive in treatment • Trusting of therapist • Able to integrate the therapist’s comments

6 10/7/2019

Pre‐occupied/Anxious Attachment • Appear interpersonally engaged, look initially easy to treat • Eager to discuss worries, relationship difficulties, and their role in these problems, might rush to expose trauma • Chaotic and contradictory representation of self and others • Easily understood or “figured out” by the therapist • Present themselves as “needy” • Cancel therapy sessions due to feeling overwhelmed • Difficulty trusting the therapeutic relationship • Feel understood and then misunderstood by therapist • No more compliant with treatment plan than dismissive clients, sometimes showing less improvement

Dismissive/Avoidant Attachment • Resistant to treatment process, skeptical of the effectiveness of the therapy • Difficulty asking for help • Retreat from help when it is offered, often saying “I’ll be ok” or “I’m fine” or “It’s not a big deal” • Therapist may feel excluded from the client’s life • Keep thoughts and feelings internal and take actions that seem impulsive/sudden • Become more distressed/confused when confronted with emotional issues in therapy • May appear quiet in session when they are thinking deeply, slow down information delivery to allow for this time

Disorganized Attachment • Terrified of relationship, fearful of the therapist being terrified by them and their problems/actions, • Fear of the therapist harming them in the relationship (therapist sending them away, not being able to help, or scared of connecting) • Client is in a bind— feels intense fear/rage but unable to be comforted, often evokes the therapist to react aggressively, punishing, or rigid in response • Inability to regulate emotions or self‐soothe • Sits further away in group, back of the room, acts uninterested, assumes rejection • Misinterprets danger, highly reactive in relationship (fight, flight, flee) • Severe impulse control issues, violence toward others • Negative feedback loop in relationships, low self‐esteem, intense shame • Lacks community, often engaged in criminal justice system • “I don’t care what anyone thinks of me”

7 10/7/2019

Where do we come in? Understanding your attachment style as a clinician is just as important for a positive treatment outcome as understanding the attachment style of the client.

Success in Attachment Focused Therapy

There has been extensive research that shows that therapeutic alliance is a larger predictor of outcome than therapeutic approach (CBT, DBT, Motivational Interviewing, etc.). The therapist’s ability to form relationships is important in alliance building; it is shown to set the foundation for the alliance.

(Beutler, 1997)

If we know that the attachment style of the caregiver is the main determinant of the attachment outcome of the child, then we can assume that the therapist’s style of attachment can affect the client outcomes in therapy.

Bowlby believed that the psychotherapist could not only become an attachment figure for the client, but also a reliable and trustworthy companion in the client’s exploration of his or her experiences.

8 10/7/2019

Experiences in Close Relationships Scale: Evaluating attachment styles in adults

Online version of the ECR Scale https://openpsychometrics.org/tests/ECR.php

How do you create secure attachment in the therapeutic relationship?

Attend to your own self‐development • Seek your own therapy (weekly if possible) • Attend trainings that expand your understanding of attachment and trauma response in self/clients • Do not minimize your own exposure to 2nd hand trauma and how that can trigger our attachment • Process client cases with trusted colleagues– no treatment plan discussion, only attachment related issues • Start to think outside of the normal “treatment plan” – step away from assignments and look only at deepening connection with the client • Develop treatment plans that look at how to increase safety and trust in the therapeutic relationship

9 10/7/2019

(continued) • Observe what happens in the therapy room, look for subtle shifts • Pay close attention to how you greet and say good bye to clients (especially body language) • Develop a predictable rhythm/routine around your therapy practice— how do you move around your office? • Create predictable check‐in around the therapeutic relationship in session • Repair any possible ruptures in the relationship, no matter how small they seem

Secure Attachment does not mean that you will be safe from bad things from happening. It means that you have a safe place to go to if you are scared or unsure in your life.

What about Codependency!?!? • If I create a secure attachment with my client will they still be able to go out into the world and be successful without me? • Is Codependency just insecure attachment playing out? • How long does it take to create secure attachment? • What happens when a client moves toward secure attachment? • What are the risks of this type of therapy? • Does self‐disclosure help with developing secure attachment?

10 10/7/2019

Our work comes first

“Many clients seek emotional proximity to their therapist, view the therapist as a safe haven when they feel distressed, and derive a sense of security from their therapist ‐‐ who then serves as a secure base for exploring threatening material. Finally, some clients also experience intense ambivalence, separation anxiety, and fear of termination.

Therapists too experience challenges in forming productive attachments, especially with particular clients. Thus, attachment theory provides a framework for a broadened conceptualization of transference and countertransference.”

(https://societyforpsychotherapy.org)

How can we connect on a deeper level with our clients? Intentional Therapeutic Interventions based on Attachment Style

Pre‐Occupied/Anxious Attachment • Therapist will need to be conscious of assisting the client in learning to contain his/her emotional experience • Bring a concrete treatment plan with goals around pacing of the completion • Increase structure in the session to create that “safe base” in a client that feels muddled • Avoid being drawn to use more emotional/experiential techniques into the therapy process; this will only increase the client’s feeling of being overwhelmed. • Create a “steady” presence • Pay close attention to any tendency to pull away from the client; this will ramp up the protest to find the secure base/safe haven. • Reflect awareness of the client pushing or pulling in the relationship during the session

11 10/7/2019

Dismissive/Avoidant Attachment • Therapist will need to be more engaged, model emotional response • Be reassuring and encouraging about therapy process and progress • Allow for emotion of the client and therapist to part of therapeutic connection • Focus on the process in the room and not the content of what the client is discussing • Steer away from focusing on the treatment plan assignments • Bring attention to emotion or awareness of likes/dislikes • Encourage emotion to be present in the room

Disorganized Attachment • Provide observations and validate their emotional/physical state in the session (“I noticed when you started talking about your dad, it created a lot of tension in your body. I can tell this relationship is hard for you”) • Be consistent with your facial expressions toward them and tell them how you feel often • If they use anger/distancing gestures, focus on staying present and track your own physical response • Create consistent routine/rhythm in the session • Stay curious about their emotional experience and steer clear of finding ways to “fix it”, they are skilled at getting rid of their feelings • Teach basic communication skills through modeling • Show how to resolve negative emotion states in the therapeutic relationship • Provide reassurance of their progress and remind them it will be a slow process and that is good (reminding them they are in control is key)

Pacing of Attachment Work • Pacing is the KEY to creating a strong therapeutic alliance and eventually moving the client toward a secure attachment • This is a skill that takes time to develop as a clinician (refer back to the attending to self‐development section) • Do not go to fast or too far in contrasting your client’s attachment style; this can cause a rupture in the relationship • If you go too fast, insecurely attached clients will not have the time to develop the “secure base” or experience the “safe haven”, which will stop their process of exploring their inner and outer worlds.

12 10/7/2019

Questions/Comments?

Exercise: Great for Consultation Groups! Think about a particularly difficult client that you have worked with. Bring their face, body posture, and communication style into your mind. • What made this client difficult? • What did they do or not do? • Were they difficult to connect with? Or did they use emotions or behaviors to push you away? • What emotions, thoughts and reactions came up in you when interacting with this client?

Contact Information Julia Murtha, MA, LADC, MHP Planting Seeds Recovery 6636 Cedar Avenue So Richfield, MN 55423 P: 612‐758‐0893 [email protected]

Stay Connected! www.plantingseedsrecovery.com or Planting Seeds Recovery on Facebook!

13 10/7/2019

Bibliography

• Van der Kolk, B. (2015). The Body Keeps Score. London: Penguin Books. • Black, S., Hardy, G., Turpin, G., & Glenys, P. (2010) Self‐reported attachment styles and therapeutic orientation of therapists and their relationship with reported general alliance quality and problems in therapy. Psychology and Psychotherapy: Theory, Research and Practice, 78(3), 363‐377. • Borhani, Y. (2013). Substance Abuse and Insecure Attachment Styles: A Relational Study. LUX: A Journal of Transdisciplinary Writing and Research from Claremont Graduate University, 2(1). • Diener, M. J., & Monroe, J. M. (2011). The relationship between adult attachment style and therapeutic alliance in individual psychotherapy: A meta‐analytic review. Psychotherapy, 48(3), 237‐248. • Diane Poole Heller, Trauma and Attachment Expert (www.dianepooleheller.com) • Dolan, R. T., Arnkoff, D. B., & Glass, C. R. (1993). Client attachment style and the psychotherapist's interpersonal stance. Psychotherapy: Theory, Research, Practice, Training, 30(3), 408‐412. • Geller, J.D. & Farber, B.A. (2015). Attachment Style, Representation of Psychotherapy, and Clinical Interventions with Insecurely Attached Clients. Journal of Clinical Psychology: In Session, 71(5), 457‐468. • George, C., Kaplan, N., & Main, M. (1985). The Adult Attachment Interview. Unpublished manuscript, University of California at Berkeley. • Horvath, A.O. (2000). The Therapeutic Relationship: From transference to alliance. Journal of Clinical Psychology, 56(2), 163‐173. • Johnson, S. (2008). Hold Me Tight: Seven Conversations for a Lifetime of Love. New York: Hatchett Book Group.

(continued)

• Kids Cooperate, image of attachment styles (www.kidscooperate.com) • Levy, K.N., Ellison, W.D., Scott, L.N., & Bernecker, S.L. (2011). Journal of Clinical Psychology: In Session, 67(2), 193‐203. • Mallinckrodt, B., Gantt, D. & Coble, H. (1995). Attachment Patterns in the Psychotherapy Relationship: Development of the Client Attachment to Therapist Scale. Journal of Counseling Psychology, 42(3), 307‐317. • Mate, G. (2010). In the Realm of Hungry Ghosts. California: North Atlantic Books. • Norcross, J.C. (2011). Psychotherapy Relationships That Work (2nd ed.). New York: Oxford University Press. • Psychalive featuring Daniel Siegel, video (https://www.youtube.com/user/PsychAlive)fs • Seigel, D.J. & Payne‐Bryson, T. (2012). Whole Brain Child: 12 Revolutionary Strategies to Nurture Your Child's Developing Mind, Survive Everyday Parenting Struggles, and Help Your Family Thrive. New York: Bantam Publishing. • Society for Psychotherapy (https://societyforpsychotherapy.org) • The School of Life, video (https://www.youtube.com/user/schooloflifechannel/videos) • Unknown Author, Strange Situation Experiment video (https://www.youtube.com/watch?v=kUoJ_NfTpvQ) • Wei, M., Russell, D.W., Mallenckrodt, B., & Vogel, D. (2007). The Experiences in Close Relationships Scale (ECR)—Short Form: Reliability, Validity, and Factor Structure. Journal of Personality Assessment, 88(2), 187‐204. • Zero to Three, Still Face Experiment by Dr. Edward Tronick video (www.zerotothree.org)