While dismissing patients avoid feelings and avoid closeness with others, the preoccupied patient is driven by fear of abandonment and seeks closeness by any means. Toddlers classified as ambivalent-resistant in their attachment styles learned that attachment figures are too preoccupied to be consistently available and responsive to the child’s needs for e.g. regulation of distress. Consequently, the child learned to be overly demonstrative about distress in order to receive much needed attention. Unfortunately for the patient, this pattern often includes low self-esteem and difficulty trusting others. Likewise, they may be helpless and demanding, and range from appearing histrionic to borderline.
When working with preoccupied patients, the preoccupied therapist may have the urge to rescue the helpless preoccupied patient [identifying with the need] or to abandon the angry, demanding one [another enactment]. Preoccupied therapists with their own abandonment fears may be unduly hurt or angry with devaluing patients, finding it difficult to ‘survive’ [Winnicott] when working with patients to whom they seem unimportant; They may feel the dismissing patient’s devaluing complaints are justified and, thus, avoid -- out of shame-- exploring the relational pattern being enacted. (Or the preoccupied therapist may feel uncomfortable with the dismissing patient’s idealization such that the therapist might prematurely disabuse the patient of this idea without first discussing the function this idealizing behavior served for the patient.)
The preoccupied patient is in need of a therapist who is consistently emotionally available and responsive, a therapist who does not mistake the patient -- seemingly readily in touch with feelings -- with a patient who is confidently able to manage those feelings. Therapists must not dissociate their own fears of abandonment and anger if they are to see the distrust and fear of abandonment that may underlie the patient’s compliance. Instead, the preoccupied therapist might use her empathy and own feelings to create with the patient a now manageable experiencing of relationship and feelings.
Wallin, D.J. (2007) Attachment in Psychotherapy Chapter 13. (Guilford Press, NY)
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