Attachment in Clinical Practice

The third Development course in the TBIPS curriculum is ‘Attachment and Affect.’ It utilizes David J. Wallin’s (2007) book Attachment in Psychotherapy (Guilford Press, NY) with its accessible style and clinically applicable explanations.

In Chapter 11, Wallin explicates how patients require our empathy, but they also need to experience within relationship with us that overwhelming feelings can be managed. Because attachment is affect regulation, patients need to experience us as able to cope with their most difficult feelings, feelings their parents may have rejected, ignored, or punished. Therapists, in order to be able to welcome in and cope with their patients’ difficult feelings, must, of course, be capable of managing their own in order to consistently communicate a desire to understand and to help.

When failings or ruptures occur, the therapist must often be the one to initiate repair -- through intersubjective negotiation -- so that the patient can experience that the relationship with the therapist can survive disappointment, anger, and disagreement (difference). This repair of ruptures strengthens the ‘secure base’ and the patient develops an increasing “confidence that the relationship can be relied on to contain difficult feelings and help resolve them.”

Managing affects together (mutual regulation) not only embodies the secure attachment, it may also, for the patient, maybe for the first time, give a new experience of having one’s feelings and intentions be consistently of interest and concern to the other (the therapist). These new experiences challenge a patient’s expectations that others are disinterested in their feelings and inner lives.

Also in Chapter 11 we find an introduction to attachment styles seen in adult patients (using separation and termination responses as indicative). Relying on the momentous research of Ainsworth in the Strange Situation and of Main in the Adult Attachment Interview (AAI) and the Strange Situation, Wallin describes what may be seen in insecurely attached (dismissing, preoccupied, and unresolved) adult patients, and imagines their attachment styles in childhood (avoidant, anxious-resistant, and disorganized, respectively).

Avoidant attachment styles, as observed in one year old toddlers in the Strange Situation, avoid turning to caregivers for comfort when distressed and avoid showing distress (emotion) because they have already learned from experience that their parents will be dismissing of their distress. These toddlers are at risk as adults to be dismissing of their own feelings and desires and to take comfort in solitary endeavors. Their narratives may be brief, and devoid of emotional language, as seen in obsessive persons.

Preoccupied adult patients, corresponding to an anxious-resistant or anxious-ambivalent attachment style in toddlerhood, may be intensely expressive of their emotions, having learned in childhood that it took a giant display to get the attention of their preoccupied caregivers.They often see themselves as helpless to external forces. Their narratives are often copious, tangential, and hard to follow.

Unresolved adult patients can often show lapses in communication as exhibited by changes in self states (dissociation) and lapses in coherence and logic. They likely had disorganized styles of attachment as toddlers with caregivers who had unresolved trauma in their own childhoods [leading the unresolved parent to behave in a frightened or frightening manner].