The Crucial Role of Attachment in Psychotherapy: A Dive into Research, Measurement and Therapy Recommendations
Bowlby’s attachment theory has been a cornerstone of psychological research and clinical practice, providing valuable insights into human relationships, emotions, and development. In the field of psychotherapy, understanding attachment is paramount, as it can greatly influence the therapeutic process and outcomes. This article delves into the significance of attachment in psychotherapy and the various ways it matters.
Attachment Matters in Psychotherapy Specifically Through the Deepened Understanding
Foundation of Emotional Regulation
Attachment relationships formed during early childhood play a pivotal role in shaping an individual's emotional regulation abilities. Research by John Bowlby and Mary Ainsworth has demonstrated that secure attachments to caregivers promote healthy emotional development. In psychotherapy, understanding a client's attachment style can help therapists comprehend the client's emotional regulation patterns, aiding in the identification and management of emotional distress and dysregulation.
Influence on Interpersonal Dynamics
Attachment patterns also significantly impact an individual's interpersonal relationships. Insecure attachment styles, such as anxious or avoidant, can manifest as difficulties in establishing and maintaining healthy relationships. By recognizing these attachment patterns, therapists can assist clients in developing more secure attachment styles, leading to improved social interactions and emotional connections.
Trauma Resolution and Healing
Attachment trauma, often stemming from early childhood experiences, can have lasting effects on an individual's mental health. Research has shown that the therapeutic relationship itself can serve as a reparative attachment experience, offering the opportunity for clients to heal attachment wounds and develop a more secure attachment to their therapist. This healing process can be instrumental in addressing unresolved emotional trauma.
Enhancing Therapeutic Alliance
The therapeutic alliance, characterized by trust, collaboration, and shared goals between therapist and client, is vital to therapeutic success. A primary therapeutic task is to provide both emotional safety and a secure base for the client right from the very beginning. Attachment theory provides a lens through which to understand and strengthen the therapeutic alliance. When therapists recognize a client's attachment needs and respond empathically, the client is more likely to experience a secure base for exploration and self-discovery. Studies of ruptures and in-session behaviors associated with different patterns of insecure attachments identify distinct ways of working with them. Furthermore, the therapist’s own attachment and mentalizing capacity also play a significant role in therapeutic success.
Measuring Attachment
Measuring attachment quality is essential for tailoring therapy to meet a client's specific needs, understanding the automated relationship patters and their potential effect on the therapeutic relationship. There are several established ways to assess attachment.
Attachment Style Questionnaires: Instruments like the Adult Attachment Interview (AAI) and the Experiences in Close Relationships (ECR) scale assess an individual's attachment style. The AAI is particularly useful for identifying attachment patterns related to childhood experiences.
Attachment Interviews: Clinicians can use structured interviews to explore a client's attachment history, relationships with caregivers, and current attachment representations.
Narrative Assessments: Narrative techniques, such as drawing or storytelling, can be employed to elicit information about a client's attachment experiences and emotions, providing insights into attachment dynamics.
Observational Measures: Observing how a client interacts with others or discussing attachment-related themes can reveal attachment patterns and needs.
The Formulator Model's Approach to Measuring Attachment
In Formulator we tackle the attachment through childhood needs and parental responsiveness to them. Our model encompasses the essential components of attachment quality. In concrete, this is how we do it. The client is asked to think about their childhood and answer to which degree their needs (list below) where met.
· Safety
· Acceptance
· Care
· Expression of emotions
· Comfortable togetherness
· Autonomy
· Boundaries
· Justice
· Social interaction needs
An individual gets feedback on both how their overall childhood attachment needs were met and how their different needs were met. This way, a clinician gets a good idea of where the parental strengths and weaknesses were.
Furthermore, the context of the intervention, the length of the therapy as well as clients preferences play an important role on how actively and whether at all the professional brings up the topic. Thus, in Formulator, the professional can choose whether to include the childhood module in the package sent to the client. E.g., in occupational and study-performance focused settings the relevance of attachment may not be as important than in settings where one needs to understand the scenery behind the psychological symptoms.
How Clients with Different Attachment Organizations Report on How Their Childhood Needs Were Met
In attachment theory, individuals can exhibit various attachment styles/patterns, including secure (healthy interdependence with others), anxious (overdependence on others), and avoidant (difficulty relying on others), and disorganized (unresoved trauma). The names vary in different therapy schools. Each attachment style is associated with distinct patterns of how attachment needs were met or not met during childhood. Here's how individuals with different attachment styles might respond to the dimensions of attachment needs.
Secure Attachment:
Safety - Secure individuals would likely report that they felt safe and secure in their parents' care during childhood.
Acceptance - Secure individuals typically report that their parents were accepting, loving, and responsive to their emotional needs.
Care - Secure individuals typically report that their parents were caring, nurturing, and attentive to their physical and emotional needs.
Expression of Emotions - Secure individuals likely felt encouraged to express their emotions and were met with empathy and understanding.
Comfortable Togetherness - Secure individuals would recall positive experiences of togetherness with their parents, feeling comfortable and connected.
Autonomy - Secure individuals typically experienced a balance between autonomy and connection with their parents.
Boundaries - Secure individuals likely experienced clear and consistent boundaries set by their parents.
Justice - Secure individuals may have been taught about fairness and justice and had parents who modeled fair behavior.
Social Interaction Needs - Secure individuals likely felt encouraged and supported in their social interactions and friendships.
Avoidant Attachment:
Safety - Avoidant individuals may downplay the importance of needs for safety, emphasizing self-sufficiency and independence.
Acceptance - Avoidant individuals might not place as much emphasis on acceptance and could value self-reliance over emotional connection.
Care - Avoidant individuals might not emphasize the importance of care, focusing more on autonomy and self-care.
Expression of Emotions - Avoidant individuals may have learned to suppress their emotions or minimize their emotional needs.
Comfortable Togetherness - Avoidant individuals may not have sought togetherness as much and may have valued independence over it.
Autonomy - Avoidant individuals may have highly valued autonomy and independence, seeking to assert their self-sufficiency.
Boundaries - Avoidant individuals may have highly valued personal boundaries and may have had parents who respected their need for space.
Justice - Avoidant individuals may not have placed a strong emphasis on justice or fairness.
Social Interaction Needs - Avoidant individuals may have prioritized self-sufficiency and might not have relied on social interactions as much.
Preoccupied Attachment:
Safety - Preoccupied individuals might express concerns about safety and seek reassurance from their parents.
Acceptance - Preoccupied individuals might have expressed a strong desire for acceptance and fear rejection.
Care - Preoccupied individuals might have been highly emotional as children, seeking emotional support and validation.
Expression of Emotions - Preoccupied individuals might have been highly emotional as children, seeking emotional support and validation.
Comfortable Togetherness - Preoccupied individuals might have sought constant togetherness and closeness to alleviate their anxieties.
Autonomy - Preoccupied individuals may have struggled with autonomy and may have been more dependent on their parents.
Boundaries - Preoccupied individuals might have had unclear or overly porous boundaries with their parents.
Justice - Preoccupied individuals may have been sensitive to issues of justice and fairness and may have felt wronged when they perceived injustice.
Social Interaction Needs - Preoccupied individuals may have leaned heavily on social interactions for validation and emotional support.
Disorganized (unresolved trauma) Attachment:
Safety - Disorganized individuals may have experienced inconsistent safety, sometimes feeling safe and other times feeling threatened.
Acceptance - Disorganized individuals may have experienced inconsistent acceptance, vacillating between feeling loved and feeling neglected or rejected.
Care - Disorganized individuals may have experienced inconsistent caregiving, with periods of neglect or over-involvement.
Expression of Emotions - Disorganized individuals may have experienced unpredictable and sometimes frightening emotional responses from their parents.
Comfortable Togetherness - Disorganized individuals may have experienced chaotic or unpredictable togetherness, sometimes feeling safe and other times overwhelmed.
Autonomy - Disorganized individuals may have experienced inconsistent boundaries related to autonomy, sometimes feeling stifled and other times unsupported.
Boundaries - Disorganized individuals may have experienced chaotic or unpredictable boundaries, with parents swinging between permissiveness and strictness.
Justice - Disorganized individuals may have experienced inconsistency in the application of justice by their parents.
Social Interaction Needs - Disorganized individuals may have experienced unpredictable social interactions within their family, sometimes feeling included and other times excluded or mistreated.
Attachment in Psychotherapy Research
Research in the field of psychotherapy has extensively explored adult attachment, considering it both as an outcome measure and a variable that can influence treatment results. Initial observations indicate that a client's attachment status is relevant to how psychotherapy progresses and concludes, and it may undergo changes as a consequence of therapeutic interventions.
A comprehensive review conducted by Berant and Obegi in 2009 noted that clients with secure attachment styles generally tend to derive more significant benefits from psychotherapy compared to those with insecure attachment patterns. Nevertheless, these findings have not consistently aligned, as certain studies have suggested that securely attached clients might not necessarily exhibit more significant improvements than their insecurely attached counterparts, as seen in Fonagy et al.'s work in 1996.
Furthermore, the strength of the relationship between attachment security and treatment outcomes remains somewhat uncertain. A prior meta-analysis conducted by Levy, Ellison, Scott, and Bernecker in 2011 indicated a small-to-moderate effect of attachment security on psychotherapy outcomes, though these results were influenced by the specific attachment style under consideration. However, considering the limited number of studies included in this meta-analysis (k = 14), evolving trends in attachment styles over recent decades, and advancements in statistical methodologies, there is a clear need for an updated study in this domain.
Levy with collegues (2018) made a comprehensive meta-analysis of 36 studies, involving 3,158 patients, which indicated that individuals with a secure attachment style prior to undergoing psychotherapy tend to achieve more favorable treatment outcomes compared to those with insecure attachment styles. Additionally, there is evidence to suggest that as therapy progresses, an increase in attachment security may align with improved treatment results. Moreover, initial investigations into moderator variables propose that individuals with low pretreatment attachment security may experience enhanced therapy outcomes when the treatment emphasizes interpersonal interactions and the development of close relationships. This group suggested several practical guidelines for psychotherapies.
Practical Insights for Psychotherapists
Assess the Client's Attachment Style
A client's attachment organization can significantly influence the psychotherapy process, therapeutic alliance, and treatment outcomes. Therefore, it's crucial for therapists to be observant of indicators of a client's attachment style.
Understand Attachment Organization
Recognize that a client's attachment organization provides valuable insights into how they are likely to respond in treatment and interact with the therapist. Expect that anxiously attached clients may require longer and more challenging treatment, while securely attached clients may progress more quickly and positively.
Address Challenges with Anxiously Attached Clients
Be aware that anxiously attached clients might initially appear engaged and cooperative but can become challenging to treat, often exhibiting quick anger or feelings of rejection. Consider adopting an approach that helps these clients manage their emotional experiences. This may involve clear articulation of the treatment framework, increased structure to counteract emotional confusion, and, at times, avoiding techniques that could overwhelm the client.
Manage Avoidantly Attached Clients
Understand that avoidantly attached clients may benefit from a therapist who balances being active and engaged while also providing enough personal space. Avoid creating a chase-and-dodge dynamic with avoidant clients.
Tailor Your Approach
Strive to strike a balance between not being too accommodating or too distant with clients based on their attachment styles. Customize your interpersonal style to avoid overwhelming dismissing clients or appearing aloof to anxiously attached clients.
Consider Interpersonal Focus in Therapy
For clients with low attachment security, contemplate providing therapies with a strong interpersonal focus to optimize treatment outcomes. Preliminary evidence suggests that individuals with low attachment security may face difficulties in treatments lacking an interpersonal component, but they may fare better in therapies with a strong interpersonal element.
Attachment Style Modification
Understand that attachment styles can be modified during psychotherapy, even in relatively brief treatments and for clients with severe attachment difficulties, such as those with borderline personality disorder. Therefore, changes in attachment can be viewed as a proximal outcome and a treatment goal.
Intervene to Change Attachment Style
Early research indicates that focusing on the therapeutic relationship and employing interpretations can be effective mechanisms for changing attachment style, especially for clients with personality disorders. However, other studies suggest that a range of treatments can be useful for altering attachment representations in clients with less severe, neurotic-level difficulties.
Conclusion
The key tenets of attachment-informed psychotherapy are: 1) the therapist–client attachment relationship is central to promoting change, 2) the recognition of attachment dynamics during therapy guides both formulation and interventions, and 3) therapy can reshape attachment dynamics. There are multiple methods for measuring attachment quality, including Formulator’s innovative approach of assessing childhood needs and parental responsiveness.
Sources
Berant, E., & Obegi, J. H. (2009). Attachment-informed psychotherapy research with adults. Attachment theory and research in clinical work with adults, 461-489.
Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G., ... & Gerber, A. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of consulting and clinical psychology, 64(1), 22.
Levy, K. N., Ellison, W. D., Scott, L. N., & Bernecker, S. L. (2011). Attachment style. Journal of clinical psychology, 67(2), 193-203.
Levy, K. N., Kivity, Y., Johnson, B. N., & Gooch, C. V. (2018). Adult attachment as a predictor and moderator of psychotherapy outcome: A meta‐analysis. Journal of clinical psychology, 74(11), 1996-2013.