GSJP Volume 16 final 100 Graduate Student Journal of Psychology 2015, Vol. 16 Copyright 2015 by the Department of Counseling and Clinical Psychology Teachers College, Columbia University 100 Rewriting History: Attachment Theory in the Practice of Adult Psychotherapy Jillian D. Farrell, B.A. Department of Counseling and Clinical Psychology Teachers College, Columbia University Jacqueline A. Carleton, PhD National Institute for the Psychotherapies Attachment theory can enhance both the therapist’s and patient’s awareness of their roles in the psychothera- peutic process, their effect on the therapeutic alliance, and their understanding of themselves and one an- other. John Bowlby (1980) proposed that the innate developmental task of infants is to seek and grow a rela- tionship with their primary caregiver, offering the child protection and security (Dolan et al., 1993; Farber et al., 1995; Levy, 2005; Sable, 2007). As an adult, the acquired pattern of attachment behavior guides how an individual relates to others, functions in interpersonal situations and relationships, regulates emotions, and re- ÁHFWV� RQ� SDVW� RU� SUHVHQW� DWWDFKPHQWV� �$WNLQVRQ� HW� DO��� ������ 0LNXOLQFHU� HW� DO��� ������ 6DEOH�� ������ =LOFKD� HW� DO��� ������� %\� UHYLHZLQJ� WKH� VHOHFWHG� OLWHUDWXUH� LQ� WKH� ÀHOG�� WKH� SUHVHQW� DUWLFOH� VWULYHV� WR� KHOS� FOLQLFLDQV� GHHSHQ� their understanding of the role of attachment theory with adult patients, in the psychotherapeutic process, as it has been elaborated in the recent literature. It is hoped that clinicians will be inspired to follow up with some of the multitudinous references we have provided to this fascinating literature. We would also hope that they realize that a great deal of evidence has accrued of the effectiveness of attachment based psychotherapy. Introduction Background John Bowlby (1980), the father of attachment theory, established a conceptual framework that con- tinues to inspire attention and research. The princi- ples of the theory address the innate developmental task of infants to seek and grow a relationship with their primary caregiver, offering the child protection and security (Sable, 2007; Levy, 2005; Dolan et al., 1993; Farber et al., 1995). This is congruent with the ethological principle that all mammals require the SUHVHQFH�RI �D�FDUHJLYLQJ�ÀJXUH�DV�WKH�SURWHFWRU�RI �WKH� fragile infant striving for survival (Bernier et al., 2002; Bowlby, 1980; Diener et al., 2011; Muller, 2009). Us- ing Bowlby’s theory as a foundation, Mary Ainsworth went on to systematically assess attachment needs and behaviors of toddlers in her well-known experiment, The Strange Situation (Ainsworth, 1985; Ainsworth et al., 1978). From there, Mary Main and colleagues developed the Adult Attachment Interview (AAI), enabling researchers and clinicians to explore at- tachment related phenomena in late adolescence and adulthood (Wallin, 2007). An enormous amount of DWWDFKPHQW�UHVHDUFK�FRQWLQXHV�WR�ÁRXULVK�DQG�WKHUH�LV� now substantial empirical support for Bowlby’s (1980) conviction that early family experience is related to lat- er personality functioning (Harris, 2004; Sable, 2007). The present paper strives to help clinicians deepen their understanding of the role of attachment theory in the psychotherapeutic process with adult patients, as it has been elaborated in the plethora of recent OLWHUDWXUH��%\�UHYLHZLQJ�VHOHFWHG�OLWHUDWXUH�LQ�WKH�ÀHOG�� knowledge and perspectives of attachment concepts are examined and integrated to form a comprehen- sive overview. The various elements of attachment theory are discussed in the context of psychotherapy, including suggestions for the application of theory to practice and possible directions for future research. 6LJQLÀFDQFH�RI �$WWDFKPHQW�7KHRU\�LQ�&OLQLFDO� Practice The phrase “attachment state of mind” denotes the way an individual in adulthood processes at- tachment-related cognitions, feelings, and memories (Atkinson et al., 2004). Attachment systems impact people’s trust in close relationships, their fears of re- jection, their weak or intense yearning for intimacy, and their tendency to favor dependency or autono- my (Meyer et al., 2001). The acquired pattern of at- tachment behavior guides how he or she relates to others, functions in interpersonal situations and re- ODWLRQVKLSV�� UHJXODWHV�HPRWLRQV�� DQG� UHÁHFWV�RQ�SDVW� or present attachments (Atkinson et al., 2004; Mi-Keywords: attachment, psychotherapy, working alliance, AAI 101 kulincer et al., 2007; Sable, 2007; Zilcha et al., 2011). Indeed, attachment theory offers a foundation from which a clinician can better understand the limitations and capacities of an adult patient through the consid- eration of childhood and current relationships that have brought about the person’s representations of the self and others (Sable, 2007; Smith et al., 2009). Utilizing attachment theory, an adult patient’s ca- pacity to form positive relationships can be examined (Smith et al., 2009). In adults, psychopathology may arise from or result in the inability to form and main- tain close relationships (Sable, 2007). Additionally, attachment theory can be understood as a theory of trauma in which the lack of and/or disruption in se- cure connections to others generates traumatic stress DQG�PRGLÀHG�VW\OHV�RI �DWWDFKPHQW��/HY\���������$Q� individual’s attachment system is associated with the capacity for intersubjectivity, affect-regulation, men- talization, and other developmental processes; thus, the disruption or weakness of these processes due to a maladaptive attachment system can weigh heav- ily on one’s functioning and be manifested in symp- toms (Bowlby, 1980; Sable, 2007). Lamagna (in press) states, “This ‘internal attachment system’, compris- ing states representing our subjective experience and VWDWHV� UHÁHFWLQJ� RQ� DQG� DSSUDLVLQJ� WKDW� H[SHULHQFH� coordinates its activity in ways that best regulate the individual’s affects, thoughts, perceptions, and behav- ior.” Research shows a convincing connection be- WZHHQ�DWWDFKPHQW�GHÀFLWV�DQG�$[LV�,�DQG�$[LV�,,�GL- agnoses (Shorey et al., 2006). Bowlby (1980) pointed out long ago that separations, losses, and other distur- bances in attachment are the foundations from which emotional distress and personality disorders arise. How Attachment Theory Is Related to Psycho- pathology in Adulthood Wallin (2007) proposes that the guiding rules of a person’s life are those evolved from the “rules of attach- ment” that were internalized and embedded in infancy through interactions with caregivers. These “rules”, in WLPH��GHÀQH�WKH�PHDQV�E\�ZKLFK�RQH�DFFHVVHV�DWWDFK- ment-related cognitions, emotions, and recollections. The attachment they had as infants has been found to be strongly linked to their psychological health as adults (Atkinson et al., 2004; Shorey et al., 2006). The individuals typically exhibiting psychopa- thology are unable to protect themselves against and/or cope with threats, stresses of human in- teraction, and the hassles of everyday life due to WKH� DEVHQFH� RI � WKH� ÁH[LEOH� SV\FKRORJLFDO� SURFHVV- es developed through early attachment experienc- es (Bateman et al., 2003; Bowlby, 1980; Levy, 2005; Sable, 2007; Zilcha et al., 2011). Losses and unre- solved experiences in a person’s attachment system can be kept hidden in a dissociated state that only releases these overwhelming experiences when pro- voked with cues relating to them (Wallin, 2007). 7KH�0RGLÀFDWLRQ�RI �$WWDFKPHQW�6\VWHPV�LQ� Psychotherapy Fortunately, attachment systems can be mod- LÀHG� E\� VXEVHTXHQW� UHODWLRQVKLSV�� RQH� RI � ZKLFK� LV� psychotherapy (Mikulincer et al., 2007; Wallin, 2007; Zilcha et al., 2011). The experience of psychother- DS\�� ÀUVW� GHVFULEHG� E\� )UHXG� DV� ´WKH� WDONLQJ� FXUHµ�� generally involves self-disclosure of concerns by the client and facilitation of change by the therapist (Leger, 1998). Vaughn and Burgoon (1976) noted, “Parsons (1951) maintains that therapy becomes necessary when the control mechanisms inherent in the reciprocities of ordinary human relationships break down” (p.256, quoted from Leger, 1998). Thus, psychotherapy, particularly attachment-focused psy- chotherapy, has the potential to transform the rigid processes of one’s attachment system to become more robust, as well as re-write the way a person views him or her self and others (Harris, 2004). The growing research in attachment is beginning to facilitate greater application of the theory to the practice of psychotherapy (Mikulincer et al., 2007; Wallin, 2007). Findings have supported the notion that clinicians’ knowledge of attachment theory en- KDQFHV� WKH� HIÀFDF\� RI � WKH� WKHUDSHXWLF� UHODWLRQVKLS� (Farber et el., 1995). Psychotherapeutic treatment uti- lizing attachment theory provides an opportunity for a patient to delve into both early and current attach- ment experiences while in a safe setting and with a safe person: the therapist (Bowlby, 1980; Sable, 2007). Attachment theory can “enrich (rather than dictate) the therapist’s understanding of his or her patient” (Steele et al., 2008), allowing the therapeutic alliance FARRELL, CARLETON 102 and intervention techniques to be designed to match a SDWLHQW·V�VSHFLÀF�QHHGV��0DOOLQFNURGW�HW�DO����������� Developmental Processes Starting In Early Attachment Experiences Internal Working Models of Attachment Internal working models are the foundations of adaptive or maladaptive thoughts and behaviors (Zil- cha et al., 2011). An individual’s unique internal rep- UHVHQWDWLRQV� VWURQJO\� LQÁXHQFH�KLV� RU�KHU�EHKDYLRUV� and security later on in life (Bowlby, 1980; Cortina et al., 2003; Harris, 2004; Lamagna, in press; Levy, 2005; Smith et al., 2009; Zilcha et al., 2011). These internal working models are organized behavioral systems and cognitive structures developed through the internal- ization of early interactions with caregivers and the environment (Bowlby, 1980; Cortina et al., 2003; Die- ner et al., 2011; Harris, 2004; Levy, 2005; Meyer et al., 2001; Mikulincer et al., 2007; Sable, 2007; Zilcha et al., 2011). Once these representations of self and others are formed, one’s expectations and style of thinking are virtually automatically implemented in subsequent relationships (Diener et al., 2011; Muller, 2009). The meaning of events is constructed to be congruent with the inner working models, whether accurate or inaccurate. Negative internal working models lead to the misinterpretation of social cues, like attributing hostility to others’ benign intentions (Muller, 2009). In other words, as a child matures through life his or her internal expectations, established from early experiences, govern the experience and navigation of the external world (Harris, 2004; Leger, 1998). The propositions of both Bowlby (1980) and in- terpersonal theorists suggest that an essential goal of therapy is the restructuring of representations of ear- ly attachment interactions and the transformation of insecure internal working models and destructive re- lational behaviors (Diener et al., 2011). These changes are thought to occur as a result of the new relationship experiences with the therapist (Diener et al., 2011). Although initially clients’ negative working models LQÁXHQFH�KLV�KHU�DWWDFKPHQW�DQG�SHUFHSWLRQV�RI �WKH� therapist, they become more secure during the course of therapy as the client is subjected to the consistency and responsiveness of the therapist (Bowlby, 1980; Mallinckrodt et al., 2005; Smith et al., 2009). For ex- ample, clients with a dismissing attachment style may be cold and unwelcoming towards the therapist at the RQVHW�RI �WKHUDS\��PDNLQJ�LW�GLIÀFXOW�WR�KDYH�D�FRQYHU- sation. After they experience the warmth and helpful- ness of the therapist at a carefully titrated pace, these clients begin to feel more motivated and comfortable sharing with the therapist and interacting in sessions. Through the internalization of the therapist DV� D� QXUWXULQJ� DQG� UHOLDEOH� ÀJXUH�� D� FOLHQW� JUDGXDOO\� builds an internal working model of the therapist DQG�FRPHV�WR�VHH�WKH�WKHUDSLVW�DV�DQ�DWWDFKPHQW�ÀJ- ure that he or she can resort to during distress, at ÀUVW� WKURXJK�GLUHFW� FRQWDFW� DQG�HYHQWXDOO\�E\� LQWHU- nalization (Bowlby, 1980; Farber et al., 1995). The evocation of the therapist by the client during emo- WLRQDO� DQG�RU� LQWHUSHUVRQDO� GLIÀFXOW\� DOORZV� IRU� WKH� employment of affect regulation strategies and the revision of maladaptive expectations and behaviors (Obegi, 2008). The changes in reaction to stressful circumstances and the experience of a positive at- tachment relationship contribute to an increased FRQÀGHQFH�LQ�WKH�VHOI �DQG�RU�RWKHUV��2EHJL�������� The internalization of the benevolent role of the therapist and the formation of a positive in- ternal working model of the therapist is critical to therapeutic change (Zilcha et al., 2011). Clients can reveal their internal working models through attach- ment behaviors, transference, narratives, and self-re- ports (Harris, 2004). In the case of transference, the patient actually projects his or her internal working models onto the therapist (Smith et al, 2009). Trans- ference can include positive manifestations that prog- ress treatment forward, or negative manifestations that may be seen as resistance (Cortina et al., 2003). Dozier and Tyrell (1998) stressed the need for the therapist to gently challenge the client’s attachment patterns, assumptions about relationships, and coping strategies in order to encourage the steady exploration of emotional and interpersonal issues. The goal is to restructure the models to be more congruent with ac- curate and current knowledge and experiences (Sable, 2007). Dozier and Tyrell (1998) termed this process a “correctional experience”. In adult patients, there is an unconscious, active adherence to the preexisting ´UXOHV�RI �DWWDFKPHQWµ��7KHUHIRUH��GLVFRQÀUPLQJ�WKH� ATTACHMENT IN PSYCHOTHERAPY 103 client’s internal working models propels the client to investigate, reevaluate, and understand past experi- ences that have shaped his/her problematic models and representations (Eagle et al., 2006; Shorey et al., 2006). Some label this type of intervention involving a push for change as “purposeful misattunement” (Shapiro et al., 1999). From this exploration, expec- tations and perceptions of the self and/or relation- ships can be revised and internal working models FDQ�EH�UHFRQÀJXUHG��=LOFKD�HW�DO����������$V�+ROPHV� (2000) describes, this restructuring of working mod- els is like “story-making” and “story-breaking”. The internal world of the adult patient is reassembled in a way that allows a more coherent narrative of the self to be formed, as well as the events of one’s life to “fall into place” (Sable, 2007). With regard to attach- ment, it is the discovery of meaning in our personal KLVWRU\� WKDW� LQÁXHQFHV� WKH� VHFXULW\� RI � RXU� VWDWH� RI � mind, rather than the actual content of this history. Attachment and interpersonal theorists agree that a therapist’s noncomplementary response to a client’s attachment tendencies promotes an opportunity for a client’s internal working models (also called “interper- sonal complementary hypothesis”) to be challenged and revised (Bernier et al., 2002; Goodman, 2010). %\�ÁH[LEO\�WDNLQJ�RQ�D�FRQWUDVWLQJ�VWDQFH�WR�WKH�FOL- ent’s rigid assumptions, no reinforcement is given to WKH� FOLHQW·V� LQÁH[LEOH� LQWHUSHUVRQDO� RULHQWDWLRQ� DQG� there is an opportunity for the client to explore alter- native expectations of the self and/or relationships. For example, a therapist treating a dismissing patient QHHGV�WR�VORZO\�HQFRXUDJH�UHÁHFWLRQ�RQ�WKH�SDWLHQW·V� emotional issues he/she is trying to ignore, rather than allowing these issues to be overlooked (Bernier et al., 2002). On the other hand, a therapist working with a preoccupied patient, who is pouring out his/ her emotional issues and is clinging to the therapist, must gradually encourage autonomy (Bernier et al., 2002). If the therapist gives in to every demand and need of the preoccupied patient, the individual’s in- ternal working model of the self will only become more enmeshed with his/her relationships and the negative attachment behaviors will be reinforced. The security of the therapist’s own attachment system, which will be discussed below, contributes to his or her capacity to adapt to the needs of the client. In some cases, it is extremely challenging or impossible for a therapist to provide the patient with the sense of security needed to establish the restorative positive relationship with the therapist (Mallinckrodt et al., 1995; Zilcha et al., 2011). If this is the case, the patient may be able, guided by the therapist, to use a current intimate relationship. Mentalization and Attachment Style Mentalization is the ability to understand hu- man action in the context of one’s underlying mental representations (Bateman et al., 2003). The capac- ity for mentalization is the foundation of a stable structure of the self and is developed through ear- ly attachment and subsequent social experiences (Gergely et al., 1996). Disorganized and/or weak early attachments can become incorporated into the self-structure resulting in the experience of oneself and others in this maladaptive, disoriented mode. In adults, there is an unconscious, active adherence to the preexisting “rules of attachment” based on these assumptions. With an unstable sense of self, the in- dividual inherently strives to defend their distorted and schematic perceptions of self, others, and rela- WLRQVKLSV�DJDLQVW�WKUHDWV�WKDW�PD\�FRQÁLFW�ZLWK�WKHVH� perceptions, perhaps through aggressive impulses or mental isolation (Bateman et al., 2003). This re- GXFHG�FDSDFLW\�WR�PHQWDOL]H�FDQ�EH�UHÁHFWHG�LQ�SRRU� interpersonal relations, maladaptive and insecure as- sumptions about oneself, and emotional volatility. In psychotherapy, the issues of mentalization can be addressed and improved (Bonovitz, 2010). The therapist can help cultivate a patient’s capacity for PHQWDOL]DWLRQ�E\�FRQVLVWHQWO\�TXHVWLRQLQJ�DQG�UHÁHFW- ing on the internal states within the patient (and with- in the therapist) characterizing the current moment (Bateman et al., 2003). The mutual exploration allows the therapist to discover links between external and internal experiences that seem incomprehensible for WKH�SDWLHQW��%DWHPDQ�HW�DO����������7KLV�FODULÀFDWLRQ�DO- lows the patient to become aware and make sense of previously ambiguous feelings about oneself, others, and relationships (Bateman et al., 2003). The argu- ment is that feelings are re-experienced and released during the psychotherapeutic process as one repro- cesses past experiences. This allows for the patient FARRELL, CARLETON 104 to organize a more accurate construction of experi- ence and restructure the self (Leger, 1998). Conse- quently, this new understanding and sense of control over one’s internal states facilitates mentalization. Internal Working Models of Patients Based On Attachment Style It is critical for the therapist to understand the nature of the internal working models each patient brings into treatment. Individuals with a secure attach- ment style hold assumptions that are both practical DQG�EHQHÀFLDO�IRU�WKHLU�LQWHUQDO�ZHOOEHLQJ�DQG�VRFLDO� experiences. Their internal working models sustain a trust in the goodness and competence of the self DQG�RWKHUV��DV�ZHOO�DV�D�GHVLUH�IRU�DQG�D�FRQÀGHQFH�LQ� relationships (Bordin, 1979; Diener et al., 2011; Levy, 2005). Individuals with a secure attachment are less restricted by internal rule-based patterning, enabling WKHP�WR�EH�ÁH[LEOH�LQ�WKHLU�LQWHUSHUVRQDO�FRPPXQLFD- tions (Wallin, 2007). This internalized positive inner working model facilitates a higher tolerance for anxi- ety, especially in novel experiences, resulting in a great- er freedom to explore the world and a more coherent integration of experiences (Mallinckrodt et al., 2005). They have overall better functioning in areas such as impulse control, empathy, and marital relations (Levy, 2005; Main et al., 1986). A more secure attachment LV�EHQHÀFLDO� IRU� WKH� W\SH�RI �PHQWDOL]DWLRQ� WKDW�SHU- PLWV� WKH� HIÀFDF\� RI � LQWURVSHFWLRQ� WKDW� FDQ� GLVFORVH� DQG�HYDOXDWH�DWWDFKPHQW�LQÁXHQFHV�RQ�RQH·V�UHODWLRQ- ship functioning and affect regulation (Obegi, 2008). In contrast, an insecure attachment style consists of internal working models that have a negative, am- biguous, and mistrusting view of the self and others (Diener, et al., 2011). Inadequate early caregiving ex- periences encode in the memory attachment interac- tions that are inconsistent (Sable, 2007). The dissoci- ated representations of attachment, hypothesized by Main as “multiple models” of attachment, are similar to Freud’s ideas regarding the dynamic unconscious. Instead of the unlimited access to attachment-related information present within secure individuals, those with “multiple models” are governed by rigidity in what they are supposed to know and feel rather than being able to use the entirety of their experiences (particularly those that are threatening). Therefore, an insecurely attached individual may feel discomfort with closeness in relationships and/or anxiety in times of separation (Wallin, 2007). The negative internal working models of the self and/or other fuel distress GXH� WR� WKH� LQVXIÀFLHQW� GHYHORSPHQW� RI � DSSURSULDWH� physiologic and affect regulation as a result of poor early caregiving experiences. In these cases, attach- ment repair must precede introspective exploration. Categorization of Attachment Patterns In regards to childhood attachment, sever- al different categorization schemes have been proposed consisting of different labels and numbers of categories. For the sake of simplic- ity, in this piece, I will focus on the categories pro- posed by Ainsworth (1978) and Main et al (1986). Their work yielded four patterns of attachment: se- cure, insecure-ambivalent, insecure-avoidant, and dis- organized (Dolan et al., 1993; Hietanen et al., 2006). Children’s attachment styles are highly correlated with similar attachment patterns in adulthood. There are also children with attachment styles deemed “cannot classify” since a clear pattern of attachment does not present itself in the assessment. But, for most, place- ment into one of the four styles of attachments is possible. A caretaker may be nurturing and responsive, promoting the child’s development of a sense of se- curity and secure attachment (Levy, 2005; Pally, 2001). On the contrary, inadequate early caregiving experi- ences could hinder processes like attaining the ability to self-regulate, as well as result in unstable attach- ment thoughts and insecure attachment (Sable, 2007). For adults, the attachment styles are conceptualized as: secure-autonomous, preoccupied, dismissing, or unresolved/disorganized (Hietanen et al., 2006). $VVHVVLQJ�$WWDFKPHQW�6W\OH� �7KH�$GXOW� $WWDFKPHQW�,QWHUYLHZ��$$,� As previously described, an infant’s early attach- ments to caregivers are internalized forming cogni- tive-affective structures (Bowlby, 1980) that evolve into similar models in adulthood and are active in one’s current emotional and relational involvements. The concept of adult attachment styles refers to in- dividuals’ comfort and position in close relationships, ATTACHMENT IN PSYCHOTHERAPY 105 their tendency to favor autonomy or dependency, as well as their anxiety regarding rejection and in- accessibility in relationships (Ainsworth et al., 1978; Meyer et al., 2001). For an attachment-informed psy- chotherapist, the initial assessment focuses on the quality of the potential client’s relationships (Cor- tina et al., 2003). A central part of the assessment will be the history of primary caregivers’ respon- siveness or inattentiveness, especially noting wheth- er the client experienced a loss of or abandonment by a caregiver, and the subsequent attachment style the client developed (Cortina et al., 2003). Attach- ment style can usually be adequately assessed with- out the complete implementation of a validated in- strument; however, a tool like the Adult Attachment Interview (AAI) is very useful (Cortina et al., 2003). The Adult Attachment interview (AAI) is the most accepted interview method of assessing adult attachment measures; however, self-report question- naires can also be used to measure attachment patterns (Eagle, 2006). The AAI, formulated by Mary Main and her colleagues, involves an hour-long interview in which an adult self-reports behaviors in intimate relationships and narrates experiences in childhood concerning early relationships with his or her parents (Bernier et al., 2002). This process unveils the per- son’s “states of mind regarding attachment” (Harris, 2004) and “autobiographical competence” (Holmes, 1995). Of primary importance, is the coherency of the narrative one relates about childhood experiences and relations. The clinician’s task is to listen to the pa- WLHQW·V�VWRU\��WU\�WR�ÀQG�PHDQLQJ�ZLWKLQ�LW��DQG�XQFRY- er the clues in the story that underlie the attachment pattern (Holmes, 1995). With treatment, the therapist and client can work jointly in re-writing the client’s narrative (Holmes, 1995). As the psychotherapeutic process unfolds, change and improvement can be DVVHVVHG�E\�WKH�FXOWLYDWLRQ�RI �D�PRUH�ÁRZLQJ��FRP- prehensible, and expressive story (Holmes, 1995). It is important to note the AAI’s focus on child- hood omits insight from some relevant relationships, such as those with siblings, marital partners, and co- workers (Cortina et al., 2003). The optimal means of assessment may be for the clinician to use the AAI with other measures or questions (Cortina et al., 2003). A measure like the Attachment Style Inter- view (ASI) may be a valuable supplement given that it concentrates on the aspects and coherence of one’s narrative, but also addresses the entire range of adult relationships (Cortina et al., 2003). There are also some measures that use a multi-item continuous scale (Smith et al., 2009), such as the Experiences in Close Relationship Scale (ECRS; Brennan et al., 1998) and the Adult Attachment Inventory (AAI; Simpson et al., 1992). These measures evaluate anxiety and avoid- ance, with lower scores on both dimensions indicating a more secure attachment pattern (Smith et al., 2009). The three insecure attachment styles discussed above are the result of poor and/or inadequate early attachment relationships. Individuals possessing these attachment styles often suffer problems in emotional control and serious psychological distress that con- tribute to their anxiety, depression, hostility, and mal- adaptive patterns in interpersonal relations (Bachelor et al., 2010). Anderson and Perris (2000) performed two studies to assess the relationship between adult attachment styles and dysfunctional working mod- els using the AAI, the Attachment Styles Question- naire (ASQ), and the Dysfunctional Working Models 6FDOH� �':0�6��� 7KH\� IRXQG� VWDWLVWLFDOO\� VLJQLÀFDQW� correlations supporting their hypotheses that secure attachment is negatively associated with dysfunc- tional assumption scores and insecure attachment is positively associated with dysfunctional assumptions. Consequently, individuals with insecure attachments have a greater need to piece together experiences that have caused the dysfunctional working models increasing distress and symptomology (Sable, 2007). Cortina and Marrone (2003) present a chart matching attachment style and type of prior caregiv- er with the related issues involving the creation of a supportive therapeutic alliance and potential solu- tions. For example, a client who is fearful of rejec- WLRQ�LV�SDLUHG�ZLWK�D�SUHYLRXV�FDUHJLYLQJ�ÀJXUH�WKDW�LV� consistently rejecting and/or unresponsive to needs (Cortina et al., 2003). An issue in therapy may be the client’s avoidance of talking about his or her ac- tual concerns and needs since there is a fear that do- ing so will lead to rejection (Cortina et al., 2003). To address this issue, the therapist must focus on con- veying the non-judgmental context of therapy and the therapeutic relationship (Cortina et al., 2003). FARRELL, CARLETON 106 The table provided by Cortina & Marrone (2003) LQFRUSRUDWHV�WKH�DXJPHQWHG�FODVVLÀFDWLRQ�RI �DWWDFK- ment styles used by Bifulco and colleagues (2002) as a guide to help the development of the alliance. However, a plausible concern for using attachment measures in a clinical setting is: if the patient is clas- VLÀHG�DV�KDYLQJ�D�FHUWDLQ�DWWDFKPHQW�VW\OH��LV�WKHUH�D� greater likelihood therapists will misinterpret experi- ences with a patient and establish their views based RQ� WKH� SDWLHQW·V� LQLWLDO� DWWDFKPHQW� FODVVLÀFDWLRQ"� Daly and Mallinckrodt (2009) interviewed expe- rienced therapists about approaches they found ef- fective for clients with particular attachment styles. Therapists reported the importance of gradually increasing the therapeutic distance with anxiously attached clients (Daly et al., 2009). Conversely, the therapists suggested a gradual decrease in therapeutic distance for avoidant patients (Daly et al., 2009). In addition to guiding the therapist’s approach for the patient, awareness of the patient’s attachment history prepares the therapist for the types of transference experiences that may occur, as well as improves the therapist’s understanding of his or her own possi- ble countertransference reactions (Shilkret, 2005). There are different manifestations of transference that patients can display, which may vary through- out treatment (Goodman, 2010). Interestingly, Freud (1912, 1913) discussed the dynamic of transference involved in psychotherapy: the unconscious negative component, the unconscious positive component, and the conscious “unobjectionable” component �*RRGPDQ�� ������� 7KH� ÀUVW� WZR� VHUYH� DV� RSSRVL- tions to treatment, while the latter represents feel- ings of value towards treatment and facilitates suc- cess in treatment (Goodman, 2010). Moreover, he LGHQWLÀHG� WKH� SDWLHQW·V� DWWDFKPHQW� WR� WKH� WKHUDSLVW� as a requirement for the occurrence of unobjec- tionable transference, which facilitates the devel- opment of the working alliance (Goodman, 2010). The “Working Alliance” in Attachment-Focused Therapy with Adults Attachment theory and research shed enormous light on both the client’s and therapist’s internal ZRUNLQJ�PRGHOV�LQÁXHQFLQJ�WKH�SURJUHVVLRQ�RI �WKHU- apeutic process, especially with regard to the creation of the working alliance (or client-therapist alliance) (Hietanen et al., 2006; Smith et al., 2009). Greenson �������ZDV�WKH�ÀUVW�WR�XVH�WKH�WHUP�́ ZRUNLQJ�DOOLDQFHµ� (Diener et al., 2011; Horvath et al., 1991), which he GHÀQHG� DV� D� ´UDWLRQDO� UHODWLRQVKLS� EHWZHHQ� SDWLHQW� DQG�DQDO\VWµ��S��������&RQVLGHULQJ�WKH�KHDY\�LQÁXHQFH� of the attachment styles of both the therapist and of the patient on the formation of the alliance, Bor- din (1979) views the alliance as “dyadic and mutual with the therapist and client as active co-constructors, constantly negotiating and renegotiating the alliance in order for successful work to take place” (Bordin, 1979; Smith et al., 2009). When it comes to the actu- al “alliance”, Bordin (1979) hypothesized the alliance to consist of three facets: the goal, the task, and the bond (Diener et al., 2011; Hietanen et al., 2006; Smith et al, 2009). The goal and the task involve the cogni- WLYH� HOHPHQWV� RI � WKH� DOOLDQFH�� VSHFLÀFDOO\� WKH� DJUHH- ment on the general objectives of treatment and the particular actions that will be employed to achieve the set goals (Bordin, 1979; Hietanen et al., 2006). The bond, the emotional and relational component, involves all the affective experiences that enables cli- ent to develop an attachment to the therapist, such as the client’s feelings of trust and empathy (Bordin, 1979; Hietanen et al., 2006). It is the attachment to the therapist that allows the client to participate in the tasks and achieve the goals (Smith et al., 2009). The opportunity for therapeutic change occurs with the therapist and client attending to and repairing ob- stacles resulting from a disagreement about one or more of the three components (Smith et al., 2009). Since times of danger or distress both activate attach- ment systems and often bring clients to therapy, re- searchers have come to link the concept of the ther- apeutic alliance with attachment theory (Farber et al., 1995; Harris, 2004; Sable, 2007; Smith et al., 2009). Research has found that a stronger alliance is asso- ciated with less distress in psychotherapy as treatment progresses (Sauer, 2010; Smith et al., 2009). In con- trast, the failure to develop an alliance can bring about a premature termination of therapy (Harris, 2004). Horvath and Greenberg (1986) developed the Work- ing Alliance Inventory (WAI) to measure this work- ing alliance, which includes the three subscales (task, ATTACHMENT IN PSYCHOTHERAPY 107 goal, and bond) (Goodman, 2010; Smith et al., 2009). The Therapist As A Secure Base The therapeutic relationship is more than a bond; it is also an attachment (Obegi, 2008; Zilcha et al., 2011). The relationship incorporates characteristics of child-caregiver relationships, such as the reassuring presence of the therapist and the possibility for emo- tion regulation ( Goodman, 2010; Meyer et al, 2001). First, the child must come to see the caregiver as a UHOLDEOH�DWWDFKPHQW�ÀJXUH�WKDW�KH�RU�VKH�FDQ�WXUQ�WR� if threatened or distressed, making them a safe haven (Eagle, 2006). Through experiences of an encouraging DQG�DYDLODEOH�DWWDFKPHQW�ÀJXUH��WKH�FKLOG�WKHQ�FDQ�XVH� the caregiver as a secure base that provides the com- IRUW�DQG�FRQÀGHQFH�D�FKLOG�QHHGV�WR�EH�PRWLYDWHG�WR� explore the world (Ainsworth et al., 1978; ,1980; Ea- gle, 2006; Farber et al., 1995; Lamagna, in press; Levy, 2005; Lipton & Fosha, 2011; Mikulincer et al., 2007). Similar to the caregiver-infant relationship, Bowl- by (1980) proposes the therapist serve as a secure base from which the patient can safely explore dif- ÀFXOW�SV\FKRORJLFDO�PDWWHUV�UHODWLQJ�WR�ERWK�LQWHUQDO� and external factors (Dozier et al., 2004; Eagle et al., 2009; Farber et al., 1995; Goodman, 2010; Holmes, 1995; Meyer et al., 2001; Schauenburg et al., 2010; =LOFKD�HW�DO����������$V�D�UHFHSWLYH�ÀJXUH��WKH�WKHUDSLVW� accepts the client’s feelings, offers emotional avail- ability, and provides regulated affect, which allows for the development of attachment (Malinckrodt et al., 1995; Mikulincer et al., 2007; Sable, 2007). The positive attachment relationship with the therapist IDFLOLWDWHV� WKH� FOLHQW·V� FRQÀGHQFH� LQ� KLV� RU� KHU� RZQ� DELOLWLHV�DQG�LQ�WKH�FDSDFLW\�WR�KDYH�IXOÀOOLQJ�UHODWLRQ- al experiences (Sable, 2007). Therapists’ empathetic presence combined with the mastery they project embeds a base that a patient feels comfortable using WR� YHQWXUH� LQWR� GLIÀFXOW� WHUULWRULHV� �+ROPHV�� ������ � %\� UHÁHFWLQJ� RQ� SDVW� OLIH� H[SHULHQFHV� DQG� HDUO\� attachment relationships with the help and support of therapists, patients can give meaning to past ex- SHULHQFHV�DQG�H[SORUH�WKH�LQÁXHQFH�WKH\�KDG�DQG�RU� have on their distress and functioning (Sable, 2007). The availability of the therapist during exploration facilitates the change needed for the client to explore DQG�PDNH�PRGLÀFDWLRQV�WR�KLV�RU�KHU�FXUUHQW�FRJQL- tions, feelings, and behaviors (Eagle et al., 2009; Ma- honey, 1990, paraphrased from Leger, 1998; Sable, 2007). This transformation towards a stable, coherent self-representation is not possible in psychotherapy without the therapist’s fundamental role as a “secure base” (Bowlby, 1980; Eagle et al., 2009; Farber et al., 1995). The empathy of the therapist, the security of the client-therapist relationship, and the safe intimate space are needed for the patient to obtain the free- dom to think and feel without the fear that his or her unstable or fragile self will be threatened or attacked. In addition to the therapist’s function as a secure base within the therapeutic setting, the patient can utilize the representations of the therapist developed through attachment, even after the termination of therapy, during times of stress in order to gain that sense of comfort and competence that allowed for problem solving during treatment, as well as to ex- plore new opportunities and relationships (Farber et al., 1995). The evocation of the therapist’s internal working model (discussed above during emotional and/or interpersonal strain can even help the indi- vidual regulate affect and change the way he or she approaches the stressful situation (Eagle et al., 2009; Obegi, 2008). The new strategies for dealing with VWUHVV� DQG� UHODWLRQVKLSV� UHÁHFW� D� SRVLWLYH� WUDQVIRU- mation in the client’s internal working models and attachment security (Eagle et al., 2009). The client’s LQFUHDVHG� FDSDFLW\� IRU� UHÁHFWLYH� IXQFWLRQLQJ� SHU- mits the construction of a more coherent narrative, ZKLFK�LV�OHVV�DPELJXRXV�DQG�FRQÁLFWLQJ��(DJOH�HW�DO��� 2009). Lipton and Fosha (2011) propose, “through meta-therapeutic processing, or metaprocessing for short, the secure attachment relationship between patient and therapist becomes the vehicle through which a patient’s right-brain experiencing of psycho- therapy is integrated with her left-brain, conscious, verbal knowing that a therapeutic experience has just occurred” (p. 271). The resulting clarity in one’s nar- UDWLYH�DQG�WKH�LPSURYHPHQW�RI �UHÁHFWLYH�IXQFWLRQLQJ� foster a sense of security and stability in the view of not only oneself, but also in the view of others. The Alliance As A Predictor of Therapeutic Outcome Research has indicated that the quality of the FARRELL, CARLETON 108 early working alliance and the nature of the thera- pist as a secure base is crucial to the therapeutic out- come (Diener et al., 2011; Harris, 2004; Horvath et al., 1991; Meyer et al., 2001; Mikulincer et al, 2007; Sauer et al., 2010; Schauenburg et al., 2010; Smith et al., 2009). Byrd et al. (2010) studied the impact of the working alliance on the patient’s attachment style during treatment, as well as the impact of the attach- ment style on the psychotherapeutic process. Results showed that two attachment dimensions (Comfort with Closeness and Comfort Depending on Others) were positively related to the alliance and treatment RXWFRPH�� $GGLWLRQDOO\�� WKH� DOOLDQFH� LQÁXHQFHG� WKH� dimension Comfort with Closeness, which, in turn, promoted more successful therapeutic outcome. It has also been proposed that therapists’ per- ceptions of the therapeutic alliance depend on the attachment style of the client, while the client’s per- ception of the therapeutic alliance was not related to attachment style (Dolan et al., 1993; Horvath et al., 1986). Therapists reported a stronger therapeutic al- liance with secure patients and a weaker alliance with patients that had a more avoidant attachment (Dolan et al., 1993). A meta-analytic review investigated past research exploring the relationship between client at- tachment and the therapeutic alliance, which consist of two categories of client attachment, clients’ glob- DO� DWWDFKPHQW� SDWWHUQV� DQG� FOLHQWV·� VSHFLÀF� DWWDFK- ment pattern to their therapist (Smith et al., 2009). The theoretical literature indicates that with regard to patients’ global attachment, clients’ secure attach- ment yields a stronger therapeutic alliance (Diener et al., 2011; Mikulincer et al., 2007; Smith et al, 2009). Similarly, those who perceive themselves as secure- ly attached to their therapist develop stronger ther- apeutic alliances (Smith et al., 2009). On the other hand, clients with an avoidant-fearful attachment pattern experience a less positive therapeutic alli- ance (Smith et al., 2009) Comparing the two catego- ries, evidence supports that the client’s attachment to therapist has a greater impact on the therapeutic alliance than the client’s global attachment (Smith HW� DO��� ������� 3HUKDSV�PHDVXULQJ� FOLHQWV·� VSHFLÀF� DW- tachment may be more valuable than measuring cli- ents’ global attachment when interested in predicting the quality of the therapeutic alliance (Smith et al., 2009). Dolan et al. (1993) also propose that perhaps more research should be done on whether therapists’ modify their interpersonal stance and intervention strategies based on the client’s attachment style and how the therapist perceives the therapeutic alliance. Studies investigating the working alliance rela- tionship have primarily focused on clients’ individual pretreatment characteristics, such as motivation and sociability (Horvath et al., 1986; Smith et al., 2009). Clients’ internal working models determine their per- ceptions of the therapist and the client-therapist re- lationship (Bowlby, 1980; Dozier et al., 2004; Eames et al., 2000; Smith et al., 2009; Zilcha et al., 2011). Especially when working with insecurely attached patients, knowledge of patients’ attachment histo- ries can provide the therapist with insight that can help them predict potential ruptures in the alliance; therefore, they can be proactive in their methods for intervening (Diener et al, 2011; Shorey et al., 2006). 5HFRJQL]LQJ� WKH� VLJQLÀFDQFH� RI � DWWDFKPHQW� H[SHUL- ences in the therapeutic relationship, Mallinckrodt, Gantt, and Coble (1995) created the Client Attach- ment to Therapist Scale (CATS) (Sauer et al., 2010). The measure contains three subscales similar to at- WDFKPHQW�VW\OH�FODVVLÀFDWLRQV��6HFXUH��$YRLGDQW�)HDU- ful, and Preoccupied-Merger (Sauer et al., 2010). A study investigating the relationship between attach- ment and the early therapeutic alliance reported that preoccupied attachment in patients predicted more frequency in ruptures, whereas dismissing attach- ment was associated with fewer ruptures (Eames et al., 2000). Attachment theory can facilitate the build- ing and maintenance of the therapeutic alliance that endows a client with a perception of safety and a motivation for deep exploration, and, thus, the pos- sibility for a positive therapeutic outcome and a re- duction in symptomology (Mallinckrodt et al., 2005). The Patient’s Attachment Style The Secure Patient During the AAI, adults with secure attachments convey coherent narratives that integrate past experi- ences in a relatively balanced manner (Mallinckrodt et al., 2005). These individuals most likely do not have picture-perfect childhoods, yet they can understand ATTACHMENT IN PSYCHOTHERAPY 109 DQG� UHÁHFW� RQ� SDVW� HDUO\� DWWDFKPHQW� UHODWLRQVKLSV�� whether they were positive or negative (Sable, 2007). Lipton and Fosha (2011) suggest, “Several decades of research on the moment-to-moment (and even milli- second-to-millisecond) interactions between moth- ers and their babies tells us that reiterative, ongoing cycles of attunement, disruption and repair in the context of emotional experiencing are the essential building blocks of secure attachment”(p. 258; Bee- be et al., 2002). This type of security in attachment LV�QHFHVVDU\�IRU�WKH�VHOI�UHÁHFWLYH�PHQWDOL]DWLRQ�WKDW� supports introspection and metacognition (Mallinck- rodt et al., 2005). With the ability to examine cur- rent and past experiences in a constructive fashion, an adult can develop a more balanced approach and appraisal of relationships, as well as better strategies for resolving thoughts, memories, and feelings that are related to distress (Sable, 2007). Thus, attachment VHFXULW\� VWURQJO\� LQÁXHQFHV� IXQFWLRQLQJ� LQ� LQWHUSHU- sonal relations, the capacity for affect regulation, and psychopathology in adulthood (Atkinson et al., 2004 Obegi, 2008). A person assessed as having a secure attachment will be more willing to self-disclose in- formation about him- or herself in psychotherapy (Atkinson et al., 2004; Mikulincer et al., 2007). There- fore, the formation of an emotional bond between therapist and patient would most likely be an easier and quicker process than with those patients lacking a secure attachment (Bordin, 1979; Smith et al., 2009). The Preoccupied Patient Among those assessed to have an attachment VW\OH�WKDW�LV�QRW�GHÀQHG�E\�D�VHQVH�RI �VHFXULW\��WKHUH�LV� greater likelihood for psychopathology, dysfunction, and distress. For preoccupied individuals, intense anxiety, hyperactivation, and defense mechanisms are maintained in order to combat feelings of insecurity and psychological distress that has resulted from in- security in early attachment experiences (Bachelor et al., 2010; Smith et al., 2009). Most likely, as children their caregivers were unpredictable leading them to develop neuroceptions of potential danger, as well as create contradictory internal representations of the caregiver (Badenoch, 2008). The disintegration characterizing their childhood experiences results in disruptions in the brain’s neural networks, bringing about emotional dysregulation and an overwhelming energy that blinds the individual from forming rea- sonable and objective perceptions (Badenoch, 2008). Badenoch (2008) terms the preoccupied individual’s internal world an “emotional jungle” (p. 70). With regards to relating with others, the mental models guiding them lead them to expect they will have jag- ged and unreliable relationships (Badenoch, 2008). They exaggerate their personal distress and have an overwhelming need for the support and closeness of others (Bernier et al., 2002; Dozier et al., 1995; Main et al., 1998). Their state of mind typically con- sists of enmeshment in past and current relation- ships, as well as confused feelings, possibly anger or fear, toward relationships (Atkinson et al., 2004; Badenoch, 2008; Bernier et al., 2002). An AAI nar- rative would consist of continuous interchanges of past and present experiences that are tangled together in a confusing disintegrated web, representing a poor sense of self (Badenoch, 2008). Their narratives may be extremely lengthy, with the clients becoming so caught up in their memories that it seems as if they are reliving past experiences (Atkinson et al., 2004). At the onset of therapy, preoccupied clients are more likely to have high anxiety and distress, and they often ruminate about what the therapist and others may have said (Atkinson et al., 2004; Mikulincer et al., 2007; Shilkret, 2005; Smith et al., 2009). They are of- ten concerned with the availability of the therapist and want to be emotionally and physically close (Mikulinc- er et al., 2007; Smith et al., 2009). The chaotic swap- ping, lack of coherency, and anxiety the patient brings to therapy can even make the clinician a bit anxious (Badenoch, 2008). In this case, it is important that the therapist be mindful and remain calm, as simply the presence of the therapist’s calmness can promote the patterning of emotion regulation (Badenoch, 2008). The Dismissing Patient Dismissing individuals, by contrast, tend to PLQLPL]H� WKH� VLJQLÀFDQFH� RI � HDUO\� DWWDFKPHQWV� DQG� believe relationships are relatively unimportant (At- kinson et al., 2004; Badenoch, 2008; Bernier et al., 2002; Mikulincer et al., 2007; Muller, 2009; Zilcha et DO����������7KHVH�SDWLHQWV�KDYH�GLIÀFXOW\�HQJDJLQJ�LQ� discussion regarding the inadequacy of their early at- FARRELL, CARLETON 110 tachment relationships, and, thus deny their feelings about these issues (Atkinson et al., 2004; Mikulincer et al., 2007; Muller, 2009; Zilcha et al., 2011). Even traumatic events will be minimized into an occur- rence that is more socially accepted (Muller, 2009). Applying the role of imagination proposed by Bono- vitz (2012), these individuals may overly use fanta- sy to avoid facing reality, resulting in rigidity in life and trouble in interpersonal relations (Bonovitz, 2012). Due to their insistence on self-reliance and VHSDUDWHQHVV��WKH\�KDYH�GLIÀFXOW\�IRUPLQJ�ERQGV�DQG� they reject or deny attachment needs (Bernier et al., 2002; Dozier, 2004; Eagle, 2006; Main et al., 1998; Mikulincer et al., 2007; Muller, 2009, 2007; Shorey et al., 2006; Smith et al., 2009; Zilcha et al., 2011). The discourse of dismissing patients’ narratives PD\�EH�ÁXHQW�� \HW� VHHPV� WR�EH�YHU\� VXSHUÀFLDO� DQG� lack details (Badenoch, 2008; Bernier et al., 2002; Dozier et al., 2004). There is either dissociation or absence of many aspects of early attachment expe- riences and emotional numbness as well (Bernier et al., 2002; Muller, 2009). Badenoch (2008) describes the mental model of a dismissing patient as an “emo- tional desert” (p. 68). The patient may describe their parents as “nice” or the relationship as “good” (Bad- enoch, 2008). When listening to these narratives, cli- nicians may struggle to grasp the internal model and community directing the patient’s mind (Badenoch, 2008). Patients may convey cues that the therapist should not probe discussion on a certain topic or in- trude in areas of their life that they insist are not trou- bling (Dozier et al., 2004). When treating a dismiss- ing patient, there may be a challenge in creating an interpersonal connection, especially since dismissing individuals often lack the ability to read others’ sig- nals (Badenoch, 2008). A particular obstacle to a ther- apist’s relationship with a dismissing client is “mutual avoidance” (Muller, 2009). The patient’s ambiguous feelings toward a trauma or attachment relationship lead the therapist to question how to react; therefore, the therapist surrenders to the patient’s pull to avoid the topic (Bernier et al., 2002; Muller, 2009). Muller (2009) suggests, “The challenge in treatment, then, is LQ�KHOSLQJ�VXFK�SDWLHQWV�ÀQG�D�ZD\�WR�WHOO�D�VWRU\�WRR� painful to speak, but too compelling to ignore” (pp.79). The Unresolved Patient Similarly, those with unresolved attachment styles often lack recollections of important experiences re- lating to attachment in childhood (Dozier et al., 2004). They are so overwhelmed by the loss or trauma they experienced that they may have a lapse in reasoning (e.g., refusing to believe a person is dead), discourse, and behavior (Dozier et al., 2004). These individuals are even more disorganized in their cognitions and behaviors due to the inability to resolve early trau- mas in attachment (Bernier et al., 2002). Their inner worlds are fragmented, consisting of both chaos and rigidity (Badenoch, 2008). The disorganization that characterizes the unresolved pattern of attachment is demonstrated when these patients discuss ear- ly attachment experiences and current relationships (Shilkret, 2005). Not surprisingly, individuals with un- resolved attachments are more likely than others to be found in a psychiatric setting (Dozier et al., 2004). While relaying their narratives, unresolved-at- tached patients’ speech may appear disorganized in, for example, the use of incorrect tenses (e.g., using the present tense when speaking about the past), long SDXVHV��DQG�LQDELOLW\�WR�ÀQG�RQH·V�ZRUGV��%DGHQRFK�� 2008). During the course of therapy, they may pres- ent as one of the other attachment styles at different times, as they sporadically vary in the symptoms they are suffering from and their affective states (Shilkret, 2005). Lamagna (in press) describes this common manifestation as “come close/stay away” messages (p.8). The patient’s lack of coherency in discourse and behavior can cause a therapist to feel unstable and confused (Badenoch, 2008). Therapy with pa- tients characterized by the unresolved attachment VW\OH�LV�ÀOOHG�ZLWK�FRQIXVLRQ��WKHUHIRUH��WKH�WKHUDSLVW� must strive to maintain calmness and clarity (Shilkret, 2005). Additionally, it is important to mention that these patients often come to therapy feeling ashamed about hurting those they loved with their unmanage- able behaviors (Badenoch, 2008). For this reason, the beginning of therapy must consist of the ther- 1 Some theorists hold that those with unresolved attachments always can be diagnosed with an additional attachment pattern simulta- neously (Main & Solomon, 1986; Badenoch, 2008). For example, a patient may have a secure attachment to his father, while hav- ing an unresolved attachment with his mother (Badenoch, 2008). ATTACHMENT IN PSYCHOTHERAPY 111 apist making a purposeful effort to provide patients with a sense of empathy, as well as emphasize the patients’ ability to change the dissociated mental models that led to regretful actions (Badenoch, 2008). The Therapist’s Attachment Style Of tantamount importance to the therapeutic en- deavor is the therapist’s attachment style (Meyer et al., 2001). Just like any other individual, the therapist pos- sesses his or her own internal working models and at- tachment patterns (Bennett, 2008). In order for treat- PHQW� WR�EH�HIÀFDFLRXV�� WKH� WKHUDSLVW�PXVW�EH�DZDUH� of his or her attachment style due to its large impact on one’s interpersonal competencies and disposition, and, thus, the client’s experience of the therapist and vice versa (Atkinson et al., 2004; Bennett, 2008; Wal- lin, 2007). The internal working models of therapists affect their patterns of self-protection, their ability to EH� VHOI�UHÁHFWLYH�� WKHLU� FDSDFLW\� IRU� FDUHJLYLQJ� �HP- pathy), their proclivity for empathic understanding and their range of affect regulation (Bennett, 2008). Cortina and Marrone (2003) suggest four import- DQW� IDFWRUV� LQÁXHQFLQJ� WKH�TXDOLW\�RI � WKH� WKHUDSLVW·V� empathetic understanding, which include: his/her own early attachment history, his/her own experienc- es as an analysand (client), his/her own experiences in clinical supervision, and his/her theoretical frame- work or biases. As a clinician, one needs to mental- ize during sessions with patients in order to separate his or her feelings and experiences from those of the patient, while simultaneously recognizing the mental states of the patient (Bateman et al., 2003). When in- WHUDFWLRQV�SURYRNH�XQFRQVFLRXV�FRQÁLFWV�DQG�ZLVKHV� in the therapist, it is possible for defense mechanisms to become mobilized and uncomfortable counter- transference to occur (Bateman et al., 2003). The phenomenon of countertransference involves the changes in the therapist’s state of mind and automat- ic verbal/nonverbal behaviors that the patient picks up, causing either the exacerbation or alleviation of anxiety and other symptoms (Pally, 2001). Counter- transference may occur due to the therapist’s need to be guarded from the patient’s transference, resulting in a distancing in the relationship; or there can be an activation of automatic internal responses in the ther- apist, causing him or her to involuntarily react with- out thinking (Pally, 2001). All of these occurrences can hinder the therapist’s capacity to be empathetic, the quality of his/her technical skills, and the capac- ity for affect attunement (Mallinckrodt, 2010). These HOHPHQWV�KDYH�DQ� LQÁXHQFH�RQ�WKH�WUHDWPHQW�FRQGL- tions and outcome, as well as the therapeutic rela- tionship (Meyer et al., 2001; Pally, 2001; Sable, 2007). Securely- Attached Therapists Therapists who are securely attached typical- ly exhibit behaviors consistent with this attachment style, such as warmth and trustworthiness, which DUH� EHQHÀFLDO� IRU� GHYHORSLQJ� UHODWLRQVKLSV� �2EHJL�� 2008). These secure attachment representations pro- YLGH�WKH�WKHUDSLVW�ZLWK�JUHDWHU�ÁH[LELOLW\��VWDELOLW\��DQG� DXWRQRP\�ZKHQ� LQ�GLIÀFXOW� LQWHUSHUVRQDO� VLWXDWLRQV�� VXFK� DV� DQ� XQFRPIRUWDEOH� ÀJKW� ZLWK� D� SDWLHQW� DQG� the inevitable ruptures in the therapeutic relation- ship (Lopez & Brennan, 2000; Meyer, 2001). Instead of acting on one’s own attachment related fears and needs, the therapist can adapt his or her behaviors to suit the needs of the patient involved in the inter- SHUVRQDO�GLIÀFXOW\�� DIIRUGLQJ�EHWWHU� FDUH� IRU� WKH�SD- tient (Cortina et al., 2003; Schauenburg et al., 2010). The study by Schauenburg et al (2010) focused on WKH� LQÁXHQFH� RI � WKHUDSLVWV·� DWWDFKPHQW� UHSUHVHQWD- WLRQV� RQ� WKH� DOOLDQFH� DQG� FRQÀUPHG� WKH� EHQHÀFLDO� effect of therapists’ attachment security on the work- ing alliance with interpersonally distressed patients. Insecurely- Attached Therapists Conversely, therapists with an insecure attach- ment style, such as dismissing or preoccupied, may KDYH�GLIÀFXOW\�ZKHQ�LW�FRPHV�WR�ZRUNLQJ�WKURXJK�DQG� dealing with ruptures given the anxiety and fear of re- jection that constitute these attachment styles (Meyer et al., 2001). Their insecure attachment needs may also lead to substandard intervention strategies and DQ�LQDELOLW\�WR�EH�VHOI�UHÁHFWLYH��%HQQHWW���������'XH� WR�WKH�ODFN�RI �UHÁHFWLRQ�LQ� LQVHFXUHO\�DWWDFKHG�WKHU- apists, they may struggle with the regulation of their own affect; therefore, they lack the ability to facili- tate affect regulation in the patient, a critical healing element in the therapeutic process (Bennett, 2008). Given that therapist attachment style predicts aspects FARRELL, CARLETON 112 of countertransference, therapists with dismissive at- WDFKPHQW�PD\�EH�PRUH�GLVWDQW�ZLWK�GLIÀFXOW�SDWLHQWV� and situations, as well as have more antagonistic coun- tertransference reactions to patients (Bennett, 2008). Those with preoccupied attachment style might fear they are inadequate and struggle to separate their own anxieties and emotions from those of the patient �%DWHPDQ�HW�DO���������%HQQHWW���������7KHVH�ÀQGLQJV� suggest that the therapist’s attachment style interacts with the client’s attachment style to determine trans- ference and countertransferences, the interpersonal experience, and, most importantly, the building and strength of therapeutic relationship (Bennett, 2008). Interaction Of Therapist and Client Attachment Styles Taking into account the importance of the at- tachment style of both clinicians and patients, it is not surprising that the interaction between the two styles weighs heavily on the therapeutic process. Some research has indicated the advantageous effect of similarities between the therapist and client re- garding attitudes, personal beliefs and values, expec- tations toward counseling, and self-concept (Bernier et al., 2002). This would lead one to think that simi- larity in attachment styles would be optimal for psy- chotherapy (Bernier et al., 2002). However, interper- sonal researchers and theorists suggest the presence of both complementary and non-complementary exchanges is superior to the employment of simply complementary or non-complementary stance (Ber- nier et al., 2002). Although interpersonal theorists believe in the need for complementary exchanges, they are in agreement with attachment theorists and studies proposing the importance of dissimilarities in the interpersonal facets of client and therapist, and the notion that noncomplementary attachment styles are optimal for treatment (Bernier et al., 2002). If the therapist reinforces the client’s rigid expectations and/or replicates the aspects of the client’s poor early attachment experiences in therapy, it can pos- sible re-traumatize the patient (Cortina et al., 2003). � %RZOE\� ������� VXJJHVWV� WKDW� WKH� WKHUDSLVW� ÁH[- ibly adopt a contrasting stance that will challenge the client’s beliefs and rigid expectations about rela- tionships (Bernier et al., 2002). Dismissing patients are prone to using defensive deactivation (active in- hibition of attachment-related material). Therapists need to challenge the client’s defensive strategy be- cause this coping mechanism will only save the pa- tient from distress for a short time and will eventually fail (Muller, 2009). According to Cortina & Marrone �������� GLVFRQÀUPLQJ� WKH� LQWHUQDO� ZRUNLQJ� PRGHOV� of dismissing (avoidant) patients’ is easier than doing the same for preoccupied patients. Whereas avoid- DQW� LQGLYLGXDOV·� SULPDU\� DWWDFKPHQW� ÀJXUHV� ZHUH� unresponsive, preoccupied individuals experienced inconsistency in their primary attachments (Cortina et al., 2003; Smith et al., 2009). As discussed before, the capacity of the therapist to carry out this adap- tation depends on his or her attachment style, with securely-attached therapists being the most adaptable (Bernier et al., 2002). The therapist’s resistance to naturally respond to the patient’s attachment tenden- cies in a conforming manner can facilitate emotion- al change and growth within the patient (a correc- tive experience) (Bernier et al., 2002; Bowlby, 1980). For example, a dismissive client may avoid spe- FLÀF� WRSLFV� FRQWDLQLQJ� GHHS� HPRWLRQDO� FRQWHQW�� ,Q- stead of courteously following the patient’s attempt to focus on nonthreatening issues, the therapist needs to carefully challenge the client’s strategies and pro- mote the gradual exploration of the more intimate LVVXHV�WKH�FOLHQW�WULHV�WR�VKURXG�ZLWK�VXSHUÀFLDO�FRQ- versation (Bernier et al., 2002; Dozier et al., 1998). On the other hand, excessively emotional or preoccu- pied patients may require interventions encouraging the control of emotions and autonomy (Bernier et al., 2002; Meyer et al., 2001). Hence, corrective ex- periences are facilitated by matching therapist with patient based on dissimilar deactivating (avoidance) versus hyperactivating (clinging) dimensions of at- tachment (Bernier et al., 2002; Tyrell et al., 1999). One study reported by Tyrell et al (1999) found that preoccupied therapists formed the strongest alliance with dismissing patients and vice versa (Bernier et al., 2002). Undoubtedly, the interaction of attachment styles in psychotherapy is impactful on the transfor- mation of patient’s maladaptive thoughts and behav- iors and the formation of the therapeutic alliance. In addition to the impact of the therapist’s at- tachment style, the style of interpretation a therapist ATTACHMENT IN PSYCHOTHERAPY 113 uses also has implications in psychotherapy (Cortina et al., 2003). Even in the context of a strong ther- apeutic relationship, certain types of interpretations FDQ�KDYH�D�QHJDWLYH�LQÁXHQFH��VXFK�DV�GHFRQWH[WXDO- ization and double binding (Cortina et al., 2003). De- contextualization refers to placing too much empha- sis on the patients’ unconscious feelings and internal mechanisms (Cortina et al., 2003). Consequently, the therapist undervalues the patients’ subjective feel- ings and the effects of the external world (Cortina et al., 2003). The other counterproductive interpre- tation, double binding, for example occurs when the therapist unintentionally instigates a feeling in the patient (e.g., makes the patient feel guilty) and then interprets that the patient possesses a guilt-ridden in- ternal world (Cortina et al., 2003). Using attachment theory as a guide, the issues of decontextualization and double binding are less likely to occur in the psychotherapeutic process given the theory’s strong emphasis on the external world’s role in develop- ment (Cortina et al., 2003). By taking into account the internal and external worlds of patients, the pa- tient is less likely to feel he or she is being blamed, which would impair progress in psychotherapy. Conclusion and Summary Attachment theory describes the instinctive style of individuals seeking proximity or protection when feeling threatened. Further, it suggests ways in which attachment behavior is affected by envi- ronmental factors (Bowlby, 1980; Sable, 2007). Re- search in attachment theory following John Bowlby has given clinicians a compelling reason to explore the actual events and relationships in a patient’s early development, as well as the patient’s distinct interpre- tations and representations of experiences (Eagle et al., 2009). Early adverse experiences with attachment internalized by the receptive infant can impede the development of psychological structures that favor resilience; therefore, the infant’s vulnerability to the emergence of psychopathology is heightened (Sable, 2007). It is suggested that, although an individual’s attachment style in infancy may be different from that of adulthood, a child’s internal working model strong- O\� LQÁXHQFHV� VXEVHTXHQW� EHKDYLRU�� DIIHFWV� WKH� ZD\� others treat them, and, thus, affects their likelihood to suffer from psychopathology (Carlson, 1998 para- phrased from Snyder & Shorey, 2006; Harris, 2004). Undoubtedly, it is the internalization of these negative early experiences that generate negative in- ternal working models (Harris, 2004; Levy, 2000; Wal- lin, 2007). With their strong impact on how one car- ries out his or her life, internal working models may give the impression of being irreversible and resolute �:DOOLQ����������$OWKRXJK�WKH\�KDYH�D�VWURQJ�LQÁXHQFH� on personality and interpersonal interactions, internal working models and one’s attachment state of mind DUH�RSHQ�WR�PRGLÀFDWLRQV�E\�PHDQV�RI �QHZ�H[SHUL- ences and relationships, with psychotherapy being a useful modality for positive transformation (Berni- er et al., 2002; Wallin, 2007). Individuals with mal- adaptive attachment styles may have impairments in critical psychological processes; such as intersubjec- tive relatedness, affect regulation, and mentalization (Bateman et al., 2003). Such dysfunctions can expose an individual to psychological, physical, and/or social distress. Key goals of psychotherapeutic treatment using attachment theory involve aiding the patient in: identifying unresolved emotions and appropriately expressing affect, developing stable internal repre- sentations of self and others, constructing a secure and coherent sense of self, and acquiring interper- sonal characteristics that promote the potential for positive relationships (Bateman et al., 2003; Holmes, 1995). Internal working models can be revised as G\VIXQFWLRQDO�UHSUHVHQWDWLRQV�DUH�FKDOOHQJHG��UHÁHFW- ed on, and transformed (McCluskey, 1999; Zilcha et al., 2011). Bowlby (1980) asserted that clients must comprehend how their working models cause their unhealthy thoughts and behaviors in order for these models to be revised (Zilcha et al., 2011). The reorga- QL]DWLRQ�RI �WKHVH�LQÁH[LEOH�LQWHUQDO�ZRUNLQJ�PRGHOV� and the therapeutic relationship allows for psycholog- ical processes, like affect-regulation, to be established, as well as new realistic views of oneself and others to be formed (Eagle et al., 2009; McCluskey et al., 1999). Attachment-informed psychotherapy has its ad- vantages since it not only focuses on the history of early attachment experiences that led to the maladap- tive attachment behaviors of the patient in treatment, but also gives the therapist guidance in what approach FARRELL, CARLETON 114 to employ for a particular patient, illuminating an op- timal trajectory of treatment (Dolan et al., 1993; Har- ris, 2004). With knowledge of a patient’s attachment style, the therapist can be sensitive and adaptive to the patient’s needs, increasing and accelerating the chance IRU�H[SORUDWLRQ�DQG�EHQHÀFLDO�FKDQJH�WR�RFFXU��(DJOH� et al., 2009). The therapist’s consistent understand- ing from the start can enhance the experience of the therapist as a secure base and strengthen the bond between the therapist and client, allowing the client to increase his or her exploration, and resolve the is- sues involved (Eagle et al., 2009). In addition to the therapist’s support in confronting negative feelings and forming new models, the patient’s experience of a trustworthy and reliable other (the therapist) is a healing element in itself (Eagle et al., 2009; Obegi, 2008). There is accumulating agreement that the qual- ity of the therapeutic alliance is one of the strongest predictors of psychotherapeutic outcome (Harris, 2004; Horvath et al., 1991; Cortina & Marrone, 2003). Some have argued that attachment theory isn’t applicable to the practice of psychotherapy (Farber et al., 1995). Hamilton (1987) believed attachment is a “background concept,” and “is all too palpable; we are surrounded by it; we can observe it; and yet, from a clinical point of view, we cannot use it directly.” (p. 69). The relationship between attachment theory and psychotherapy may not now boast enough em- pirical research for an explicit “attachment therapy” for adults, yet there continues to be growing evidence and innovative interventions supporting the bene- ÀWV� RI � DSSO\LQJ� DWWDFKPHQW� WKHRU\� DQG� UHVHDUFK� WR� the psychotherapeutic process (Eagle et al., 2009). As more studies are undertaken, the importance of attachment theory and its applicability to practice becomes better understood. Evidence suggests that attachment theory can enhance both the therapist’s and the adult patient’s awareness of their roles in the psychotherapeutic process and therapeutic alliance. Additionally, attachment style it is a strong predic- tor of outcome for psychotherapy. 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