What kind of treatment is the most effective for attachment?

Differentiation in the therapy process, believes that attachment theory keeps clients functioning as needy children.

While there are no formal protocols, standardized techniques, or formal methodology for “doing” attachment-based therapy (other than the adult attachment interview), over the years, some general maxims have emerged informally for bringing attachment issues deep into clinical work.

Four of these maxims of attachment theory or conditions for therapeutic change upon which most attachment-oriented therapists would probably agree are:

  1. Insecure, ambivalent, avoidant, or disorganized early attachment experiences are real events, which–according to attachment theory–can substantially and destructively shape a client’s emotional and relational development. The client’s adult problems don’t originate in childhood-based fantasies.
  2. The attachment pattern learned in early childhood experiences will play out in psychotherapy.
  3. The right brain/limbic (unconscious, emotional, intuitive) interaction of the psychotherapist and client is more important than cognitive or behavioral suggestions from the therapist; the psychotherapist’s emotionally-charged verbal and nonverbal, psychobiological attunement to the client and to his/her own internal triggers is critical to effective therapy.
  4. Reparative enactments of early attachment experiences, co-constructed by therapist and client, are fundamental to healing.

This isn’t psychotherapy for the fainthearted. Any therapist working within attachment theory or working with those with the associated attachment disorders must stay present, not only to the client’s emotions, but also to their own.

the associated attachment disorders
Any therapist working within attachment theory or working with those with the associated attachment disorders must stay present, not only to the client’s emotions, but also to their own.

This may sound suspiciously like the familiar, old rubric, “be aware of transference and countertransference,” but it actually calls for something tougher than merely intellectually performing that task.

With attachment theory and attachment-based therapy, the therapist is asked to stay in the right brain and fully experience the client’s feelings, no matter what comes up for them or what raw emotion is triggered from their own history. In other words, the therapist isn’t just an observer of the client’s emotional journey or even a disinterested guide, but a fellow traveler, resonating with the client’s sadness, anger, and anxiety.

Rather than recoiling from the intensity of the client’s experience, the therapist is providing the stability (the ballast, so to speak) to keep the client feeling not only understood, but safely held and supported, through tone of voice, eye contact, expression, posture, as well as words.

Obviously this kind of demanding work, more than some other modalities, requires therapists to have their own inner act together. “We are the tools of our trade, the primary creative instrument with which we do the work,” says California clinical psychologist David Wallin, author of Attachment in Psychotherapy. Our ability to use ourselves effectively in this intense work is therefore inhibited by our own core emotional vulnerabilities.

As Wallin has written, “If in childhood a certain quality of expression such as anger cannot be felt or experienced, then we cannot relate to this expression in a patient.”

Therapists need “binocular vision,” says Wallin, to keep “one eye on the patient, and one eye on ourselves.” In fact, the therapist may need something like “triocular” vision as he tries to be in the client’s mind, in his own mind, and in between the two minds, establishing and maintaining between himself and the client mutually resonant affective, cognitive, and physical states of being.

People with insecure attachment styles may need put some therapeutic effort into things. Sometimes though, I think that people who find partners, friends, support systems, etc., that are willing to engage in conscious or intentional relationships with them, can heal attachment issues.

the associated attachment disorders
the associated attachment disorders

To review…

A child who is securely attached has their inner experience (feelings, thoughts, memories, images, interpretations etc.) accurately mirrored back to them, consistently, and without overwhelming anxiety. An important skill is then developed. It is the skill of mental processing (the capacity to clearly understand, and tell the difference between, the social world and one’s internal world). This skill leads to an ability to understand emotions and process them (or emotional regulation, ability to self-soothe/validate).

Sometimes a child’s needs are not obvious. For example, if the child has a sensitive temperament and the parents do not, it can create attachment problems (see Marsha Linehan for more). Parents must be emotionally intelligent enough. It is what Winnicott called “Good Enough Parenting). Attuned. The greatest gift they can offer is to do their own “work” in therapy (or otherwise), to reduce projection/transference and internalization into the child. For a less cerebral understanding, I think Roger Waters song with Pink Floyd, “Mother,” expresses internalization problems profoundly.

Watch it if you dare!

There are four adult attachment styles:

1. Anxious (also referred to as Preoccupied)

2. Avoidant (also referred to as Dismissive)

3. Disorganized (also referred to as Fearful-Avoidant)

4. Secure

ANXIOUS/PREOCCUPIED STYLE

Potential partners are seen through an “I’m not okay, you’re okay” lens. Being alone causes high levels of anxiety. In cognitive behavioral terms, the thinking error of black/white thinking, or the “Binocular Trick” (Burns) is activated. They can compulsively seek approval due to strong fears of abandonment. Emotional safety is a priority. The responsiveness is seen as the cure for anxiety (the opposite of “self-validation”). The absence of intimacy can lead to clinging and demanding. It is a desperation for love. The partner can feel suffocated. Stress can be difficult because stress can active the attachment system.

If severe, there could be problems with Histrionic, Avoidant and Dependent Personality traits.

AVOIDANT/DISMISSIVE STYLE:

The dismissive types can see themselves as rugged individuals or lone wolves, as strongly independent and self-sufficient (the Hemingway ideal). These people can have high self-esteem and a positive view of themselves. They tend to believe that they don’t have to be in a relationship to feel complete. They do not want to depend on others, have others depend on them, or seek support and approval in social bonds.

Sound pretty good to me!

Not. Because they generally avoid emotional closeness. They also tend to hide or suppress their feelings when faced with emotional processing. It is no way to live.

If severe, can have Schizoid, Narcissistic, Antisocial, and Paranoid Personality traits.

See this great song to know why “no man is an island.”

DISORGANIZED and FEARFUL-AVOIDANT

Tends to show unstable emotional reactions in their relationships. The partner is the source of fierce desire and intense fear. They want intimacy and closeness but experience troubles trusting and depending on others. They do not regulate their emotions well and avoid strong emotional attachment due to their fear of getting hurt. Abandonment is the most terrifying of all.

Tends towards Borderline Personality traits.

SECURE ATTACHMENT

The secure attachment style implies that a person is comfortable expressing emotions openly. Adults with a secure attachment style can depend on their partners and in turn, let their partners rely on them. Relationships are based on honesty, tolerance, and emotional closeness. The secure attachment type thrives in their relationships, but also don’t fear being on their own. They do not depend on the responsiveness or approval of their partners and tend to have a positive view of themselves and others.

Attachment-Oriented Interventions (to be only discussed or tried with therapist and doctor!)

SSRI’s and Mood stabilizers—for emotional dysregulation and impulsivity.

Antipsychotics—for cognitive-perceptual symptoms.

Psychotherapy (see Wiki article, it’s great).

Mentalization:

Mentalization is a process. It is how we make sense of each other and ourselves. When one’s own inner experience, and therefore of others, a maladaptive response to anxiety results, and anxiety and depression are not then far away. When a person who is vulnerable to mentalization problems, emotional dysregulation often occurs. Mentalization can help a person regulate themselves via relationship congruence. This is the “talking cure” Freud emphasized. Transference analysis is also part of this intervention.

Schema-focused therapy (SFT)

The idea is for the therapist to modify the clients’ impaired schemas (a schema is an impaired mental mode or thought process. For example, filtering out the positive and only seeing the negative). It is close to CBT or cognitive behavioral therapy. I would research David Burns “thinking errors, as well as the Wiki article or Schema therapy, as an adjunct.

What does this all mean?

1. It is the relationship that heals.

2. A person’s relationship to their inner experience, and all the anxiety that boils up within, is the root cause of inorganic mental illness.

3. This means there is hope!

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