Episode 069: Therapeutic Alliance Part 6: Attachment Types and Application
On this week’s episode, I talk about how attachment theory can be a powerful predictor in helping someone move forward past trauma and develop attachment to their therapist in a healthy and therapeutic way.
By listening to this episode, you can earn 1 Psychiatry CME Credits.
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Article Authors: David Puder, MD
There are no conflicts of interest for this episode.
What Is Attachment?
Attachment in infants is primarily a process of proximity seeking to an identified attachment figure in situations of perceived distress or alarm for the primary purpose of connection.
Attachment patterns lead to expectations and anticipations of how future relationships will unfold.
One of my favorite videos about attachment theory is The Still Face Experiment. Check it out, then come back and finish reading this blog: Click here to watch the Still Face Experiment.
As you can see, true attachment work is about mirroring emotions, play, and security. Attachment is a regulator of emotional experience, and the type of attachments we form with our primary caregivers will be a predictor of the types of attachment we expect to form in the future, and will recreate for the rest of our lives out of habit, unless they are otherwise healed, fix, or changed through other interactions.
Therapy Is An Attachment Relationship
It is an intensely focused relationship that involves acceptance, trust, unconditional positive regard, hope, attunement, tolerance, and mending empathic strains and ruptures. There is also emotional contagion between a therapist and patient, with transference and countertransference.
When used and understood correctly, therapy can help regulate emotions and anxiety. There is an implicit, intersubjective, right brain to right brain, emotional transacting and regulating mechanism in the caregiver-infant dynamic that extends to the therapist-patient relationship. As intense as the therapeutic relationship is with a patient, it is important for therapists to maintain their own therapeutic relationships outside of their practices with friends, coworkers, and by practicing what they preach and seeking their own therapy.
Ideally, when the patient feels strong negative feelings towards us, which they will if they have attachment trauma from childhood, we help them navigate as we empathize with those negative feelings so that the attachment remains, but the emotions are regulated. When a patient is struggling with self-regulation and the functional origin of the bodily-based implicit self, there is an internalized component of that. If a patient is having difficulty modulating their stress and self regulating, this can come out in all kinds of ways—self harm, cutting, binging, purging, drug and alcohol use. A healthy attachment is helpful in changing those behaviors because it helps the person regain self regulation.
The Attachment System
Oxytocin is generated during childbirth and nursing, which helps the mother bond with the fetus and the child, then helps the child attach to the mother. It promotes trust, relaxation, and desire for closeness. Then, when the child is older and experiences anxiety, it seeks closeness.
Healthy attachment forms when the attachment figure attunes to the child’s signals, interprets them correctly, and attends to them promptly and appropriately.
Interactions with attachment figures and the child develop consistent models for how attachment will take place, and over time these become a preferred attachment strategy of relating.
THE EXPLORATORY SYSTEM & ATTACHMENT
This originates in opposing motivations with the attachment system, but exist in a state of interdependence. The child’s secure attachment is a precondition of the infant’s ability to explore his environment and experience himself as an agent and self-effective individual. From 7-8 months (crawling) onward, the mother must allow exploring while setting limits on it, but also be available as a secure base for “emotional refueling.” If the mother clings to the child, not giving sufficient room for exploration (likely due to her own fear of abandonment or fear that something might harm him), the child will not develop a secure attachment.
We can see this in patients, as adults, when they desire to move from a management position to desiring to be a business owner. If they have secure attachments, they will be more likely to venture into new territory. The cortisol level in the infant brain is significantly influenced by mother-child interaction. If the child has been through traumatic events that have not been attuned to or processed through, the attachment will be strained.
Studies show that mothers think they are more attuned to their infants than they actually are, so it’s important to focus on quality time with your child. I often see an anxious mother with a child who is clingy. This is because whenever the child explores, their exploration is met by the mother’s anxiety and fear, so the child learns to not explore.
As I am playing with my children, I like to help them understand their emotions by helping them name them. When they are crying, I may say, “you feel sad, you feel sad, it makes sense you feel sad.” Acknowledging the emotions out loud, helps them to feel empathized with and understand what the names to their emotions are, and that they are valid.
ADULT ATTACHMENT INTERVIEWS (MARY MAIN AND GOLDWYN)
When doing an adult attachment interview, there are common ways different adults with the four different attachment styles respond. Here are a few things that have been noted:
Secure or “Free-autonomous”
Patients describe parenting situations as loving, caring and comforting. They are able to talk in a detailed and thoughtful way about their experiences, and they have a high level of self-reflectiveness. Another type of the secure interview is “earned secure,” which can report negative experiences coherently, due to later experiences with important attachment figures or through psychotherapy.
Dismissing (Avoidant)
These people have few memories of their childhood. They ascribe little importance to attachments in their lives and they develop avoidant attachment style children.
Preoccupied (Anxious)
They give a plethora of details, entanglements and contradictory statements. The degree that the interviewee does not recognize the contradictions in their own statements is remarkable. They develop anxious attachment style children.
Unresolved (Disorganized)
Many statements are characterized by disorganization and disorientation. These can be borderline personality disorder patients where speech, thought process, and descriptions of affective experiences tend to break down. It may include psychotic sequences, “psychic disorganization.” They are more likely to have experienced trauma, extreme loss, maltreatment and abuse.
There is a 70% correspondence between parental attachment styles and child attachment classification, and 75% if just secure and insecure attachment categories.
4 Attachment Types
As a child grows up, there is an 80% congruence between attachment style at 12 months and 6 years old in one study, and less congruence into adolescents.
Here are the four attachment types:
Secure Attachment
Parents give sensitive, loving care
Soothe him when he cries, keep him warm, protected, fed
High sensitivity
Attuned to the infant’s signals with attentiveness
Not externally or internally preoccupied with her own needs and wellbeing
Appropriately interpret and decipher the meaning of the child’s crying (hunger, illness, pain, boredom, overstimulation, dirty diaper, boredom, pain)
Not interpreting needs as a result of her own needs or by projection of these needs onto the child
Respond appropriately (correct amount of nourishment, soothe the child)
Not overstimulating or understimulating
Prompt response that does not cause intolerable frustration for the child
Child develops:
Confidence that others will be helpful when appealed to
Becomes increasingly self-reliant
Becomes bold in exploration
Becomes cooperative with others
Sympathetic and helpful to others distress
Can tolerate and integrate negative experiences and emotions
Strange Situation (the mother leaves the child in a room for a bit, then returns)
Child follows mother to door both times, call for her, many finally cry and show distress, they react with happiness when the mother returns, reach out their arms, want to be consoled, seek physical contact, then become calm and return to play
Protective factor:
May protect against psychopathology in later life despite subsequent traumatic experiences
Anxious “Ambivalent” Attachment
Parent:
Responds to child’s attachment behavior tardily and unwillingly and is regarded as a nuisance
Child:
Apprehensive that his caregiver will be missing or unhelpful when he needs her so is reluctant to leave her side
Unwillingly and anxiously obedient
Unconcerned about the troubles of others
Maintains contact with the attachment figure, heightening the expression of fear and anger, in the same way that the adult continues his or her internal conflict with his early caregivers
Strange Situation (the mother leaves the child in a room for a bit, then returns)
Child demonstrates the greatest distress after separation, crying intensely and when the mother returns it takes much longer to console, when the mother picks child up; it wants physical contact/closeness but is also aggressive (kicking, hitting, pushing, turning away)
10-20% in various longitudinal studies
Avoidant Attachment
Parent:
Actively rejects child
Child:
Avoidance competes with the desire to be near
Angry behavior
Age 6: do not talk about emotions involving attachment or they are overwhelmed so that they had a hard time coming up with solutions to the separate situations shown in the images
Age 10: mentioned negative feelings less often and were very reserved during the interview when emotionally laden subjects touching on their own feelings were brought up
Reduces the effect of frustrating experiences by cutting off anger and distress
Strange Situation (the mother leaves the child in a room for a bit, then returns)
When mother leaves they display little protest and display no clear attachment behavior, they continue to play but with less curiosity or persistence, when mother returns they do not ask to be taken up in her arms
Show higher levels of cortisol than securely attached or anxiously attached
30-40% in various longitudinal studies
Disorganized Attachment
Prevalence:
15% of healthy children born term to parents under low levels of social stress
Psychosocial risk factors include poverty, violence, poor living conditions. These also increase mother’s risk to have hostile and helpless behavior towards their children
Parents
Have experienced traumas as loss, separation, maltreatment and abuse and carry these experiences into their relationship with their child
Working through trauma can help
Mother is simultaneously a safe emotional haven and a source of fear and threat because she behaves aggressively and frightening manner in attachment situations or she herself is frightened
Pervasive pattern of extremely inadequate, insufficient or contradictory responses when the infant need for closeness and protection is activated in threatening situations
Such as abrupt separations as a result of caregiving situations
The longer the duration of early deprivation under institutional conditions the more pronounced the symptoms of ADHD and the symptoms of an attachment disorder
Child:
At-risk samples have significantly higher rates, such as premature children with periventricular leukomalacia (from brain bleeds), postnatal hypoglycemia, early abuse, deprivation
Up to 80% of kids who have been neglected, mistreated, or abused exhibit disorganized behavior such as trance-like states, frightened behavior vis-a-vis the mother, stereotypic motor behavior, contradictory behavioral patterns
Affective lapses in addition to motor agitation, throwing themselves on the floor in a rage (not a limit setting resulting tantrum)
Often rejected by peers leading to aggressive behavior which is met with attempts to structure and control such behaviors (hiding the need for attachment relationships)
Strange Situation (the mother leaves the child in a room for a bit, then returns)
Ran towards their mother, stopped short halfway, and then ran away from her, repetitive stereotyped behavior and movement patterns may be observed, as if the attachment system has been activated but could not be expressed in clear behavioral strategies
Seen as early as 12 months of age
TRANSLATING THESE ATTACHMENT STYLES INTO THERAPY:
Stay emotionally attuned to the moment to moment changes in emotion
Watch for the patient’s cues of distress
Help them put words to their emotions
Foster emotional expression in regard to attachment issues
Function as a reliable, secure base from which the patient can engage in
problem solving
Have the flexibly to handle both closeness and distance in interactions with patients
Facilitate joint examination, awareness and discussion of the therapeutic relationship and its vicissitudes
Know that the therapist serves as a model for dealing with frustration, intense disruptive emotions and engaged unwavering commitment
Encourage the patient to think about what attachment strategies he is using in interacting with you and in his dealings with other important relationships
Help the patient put into words concerns about separateness and his separation and stranger anxieties
In Conclusion
I hope this has helped you, and will help you with your patients. I get messages from some of you saying that this podcast has helped you know how to better connect to your patients, and that is the entire reason I do this podcast. If you have questions, jump on my Instagram or Facebook post for this episode and put up a comment. If you have not already checked out the prior therapeutic alliance episodes, check them out here:
Therapeutic Alliance Part 2: Meaning and Viktor Frankl’s Logotherapy
Therapeutic Alliance Part 3: How Empathy Works and How To Improve It
Therapeutic Alliance Part 4: What is Transference and Countertransference?