The Therapeutic Process Using an Attachment-based Approach By Paul Renn

Attachment theory and infant research have demonstrated that psychological organization is an adaptation aimed at preserving critical, life-sustaining relationships. Attachment classifications are simply ways of describing and organizing attachment phenomena. These phenomena, and the processes they represent, are the focus of clinical work, not the classifications per se. A basic understanding of attachment theory and research sensitizes the therapist to the nature and functioning of the attachment system and aids in the observation and recognition of attachment phenomena, as revealed in the violent client’s speech and behaviour.

The initial interview provides an ideal opportunity to begin to listen for attachment phenomena, as manifested in the client’s talk about his or her relationships with parents, partners and children. Familiarity with adult attachment research will guide the therapist to listen to the fluency, coherence, affectivity and flexibility in the client’s narrative descriptions of early childhood attachment experiences. This provides the means of identifying his or her particular ways of regulating and defending against attachment-related memories and feelings. Attachment research also alerts the therapist to listen for themes of attachment trauma in the form of loss, neglect, rejection, abandonment and abuse in the client’s narrative. Such narratives can tell the therapist a great deal about the client’s capacities to hold and reflect upon their own and the other’s mental states in making sense of behaviour and relationship patterns, and, by extension, inform us about their early intersubjective experience and developmental trauma. These narratives also offer an opportunity to evaluate the client’s attributions of the other – the nature and affective qualities of her or his internal representations of the other.

Adults who have developed a dismissing attachment style avoid intimacy and exploration of painful thoughts and feelings. By contrast, those who have created a preoccupied attachment style are angrily enmeshed with their past and current attachment figures. These contrasting adult attachment styles are captured in attachment research utilizing the Strange Situation Procedure and the Adult Attachment Interview. Findings show that, while the avoidant infant and dismissing adult develop a state of mind that values emotional self-reliance and separateness, the ambivalent/resistant infant and preoccupied adult develop a state of mind that is angry, frightened and anxious about being separate and autonomous. These states of mind give rise to attachment behaviours and phenomena that are communicated, in part, via the client’s particular discourse style. Being aware of our own predominant adult attachment style may help us, as therapists, to recognize and understand the enactments that we inevitably get drawn into with our clients and inform how best to repair such ruptures to the working alliance.

In clinical practice, then, attachment theory and research is used to conceptualize the developmental antecedents and interpersonal features of the adult client’s problems, particularly his or her strategy for managing closeness and distance, separations and reunions in intimate relationships, and the influence of these phenomena on the formation of the therapeutic alliance. Attachment theory and research provide both a particular way of listening to the client’s story and of understanding the clinical process. An aspect of this process involves identifying similarities in the complex dynamic interplay between the client’s early relational matrix and his or her current intimate relationships, including that with the therapist. This facilitates an understanding of the way in which archaic, non conscious cognitive-affective working models of attachment are being perpetuated in the here and now, actively mediating and distorting the person’s attachment-related thoughts, feelings and behaviour, particularly at times of heightened emotional stress – how the relational past lives on in the interpersonal present.

From an attachment/trauma perspective, the client’s symptoms, destructive and self-destructive behaviours are understood as expressing unprocessed traumatic experience imprinted in implicit-procedural memories, as represented in confused, unstable self-other working models. These non conscious state-dependent memories and patterns of expectancies organize the person’s experience and emerge in the relational system or intersubjective field, being communicated directly to the therapist via the client’s narrative style and expressive behavioural display. This, in turn, activates a matching countertransferential or psycho-physiological response in the therapist, enabling the therapist to participate in the subjective experience of the client in terms of shared attentional, intentional and affectional states of mind.

The developing attachment relationship with the therapist provides a secure-enough base from which the client can explore his or her self-states, as reflected in the mind of the therapist moment-by–moment, thereby unlocking the affective components of their unresolved trauma. Crucial aspects of the therapeutic process consist in the repair of inevitable ruptures to the therapeutic relationship, the interactive regulation of heightened affective moments, the provision of new perspectives, the re-organization of maladaptive patterns of expectancies, the transformation of implicitly encoded representations, and the promotion of reflective functioning or mentalization.

An emotionally meaningful therapeutic relationship facilitates a collaborative co-construction of the client’s dissociated traumatic experience and promotes the recognition of the mental states that motivate human behaviour in various relational contexts. More specifically, the process of interactive regulation of affect facilitates the recognition, labelling and evaluation of emotional and intentional states in the self and in others. This, in turn, engenders a coherent, secure and agentic sense of self as archaic internal working models are revised and updated and new relational models develop. This, together with the client’s growing realization that he or she can contingently influence the therapist and, by extension, others in everyday life, engenders a secure sense of self and recognition of other people as separate, differentiated subjects who can be related to in non coercive, non destructive ways.

The enhancement of the client’s ability gradually to organize and integrate error-correcting information consists, in significant degree, of the moment-to-moment micro-repair of misattunement or misaligned interaction – an intersubjective process operating at the level of procedural or implicit relational knowing. The therapeutic process is informed by the tracking and matching of subtle and dramatic shifts in the client’s mood-state as they narrate their story. This interactive process leads, in turn, to the recognition of the existence of the therapist as a separate person available to be used and related to intersubjectively within a shared subjective reality.

By these means, the therapist’s facilitating behaviours combine with the client’s capacity for attachment. Though operating largely out of conscious awareness, this process of mutual influence or contingent reciprocity engenders a sense of safety and security and thus the development of a working alliance or attachment relationship that facilitates a collaborative exploration and elaboration of painful, unresolved clinical issues and dissociated traumatic self-states underlying the person’s problematic behaviour. Key aspects of this intersubjective and reparative process are the dyadic regulation of dreaded states of mind charged with intense negative affect and the co-construction of a coherent narrative imbued with personal meaning.

Optimally, the therapist becomes a new developmental object, the relationship with whom provides a corrective emotional experience, thereby disconfirming the client’s pathogenic transference expectations. This process enhances the client’s capacities for affect regulation and reflective functioning or mentalization. This, in turn, strengthens the insecure/unresolved client’s ability to activate alternative mental models of interaction, enhances their capacity to empathize with others and so make more moral, reasoned choices, and reduces their tendency to deploy mental defences of perceptual distortion, defensive exclusion and selective inattention in stressful situations that generate a sense of endangerment to the self and a concomitant increase in the risk of destructive and self-destructive behaviour.

From a neurobiological perspective, the process of affect regulation, so central to attachment theory and research, links non verbal and verbal representational domains of the brain. This process facilitates the transfer of implicit-procedural information in the right hemisphere to explicit or declarative systems in the left.

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