Monday, February 18, 2019

Utilizing Attachment Theory with Adult Patients: Avoidant--Dismissing

A toddler classified as avoidant --who learned s/he could not turn to attachment figure(s) in times of distress -- can grow up to be avoidant of genuine intimacy and dismissing of feelings in self and others. Such adults in the clinical situation often overvalue self-sufficiency and can appear obsessive (control others and fear being controlled), alexithymic, schizoid, or narcissistic. It is hard for them to expect help from the therapist and, depending on which self-state is present, may keep their distance by being angry, or by idealizing or devaluing the therapist, or by being controlling.

Therapists, too, bring their own attachment styles to the clinical situation. A dismissing therapist may collude with a dismissing patient in avoiding affect. Or such a therapist may seem cold and distant, or may be controlling. The therapist may also collude with the dismissing patient’s idealization of the therapist (the patient having the need to feel special with a special therapist, and the therapist enjoying too much the patient’s admiration without questioning the patient’s perception that the therapist needs to be “propped up.”) Power struggles with dismissing patients bring up issues of submission or of being controlling, with their respective feelings of resentment  or guilt in the therapist. With preoccupied patients, dismissing therapists may find the demands for closeness and the emotional displays too unwelcome.

We know that avoidant toddlers seem unaffected by the departure of their mothers, but actually have increased galvanic skin response, heart rates and cortisol levels. One therapist reported that she thought her patient, a divorced accountant, had no feelings or attachment toward her, but his smart watch --which kept track of his heart rate and said ‘Good job!’ after his daily work outs-- would say ‘Good job!’ at the end of sessions [patient’s heart had been racing in session though his affect had appeared stable], a reminder to follow evidence of affect as communicated bodily.

Likewise,  sharing our own affective participation with our patients can help them “integrate their own dissociated feelings.”[p. 212] Wallin advocates a balance of empathy and “confrontation” with dismissing patients. He defines ‘confrontation’ as our “deliberate or spontaneous expression of our subjective experience of what it’s like to be on the receiving end of the patient’s communication.” [p. 213]

Wallin, D.J. (2007) Attachment in Psychotherapy Chapter 12. (Guilford Press, NY)

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