Attachment theory applied to practitioner and client

Authored by Henry Strick van Linschoten

This is an important application of attachment theory. By making a broad assessment of the attachment style of client and therapist, it becomes easier to understand processes and even enactments in the therapeutic relationship. It is rare that clients are formally assessed for their attachment style, either by an AAI or a self-reporting instrument. Overall there are similarities between this application of attachment theory and that for couple and family therapy dynamics. Two main sources are Allen (2012) and Wallin (2007).

Client attachment patterns – Allen

There are a number of implications that arise out of understanding attachment styles for clinical practice. The therapeutic relationship is essentially asymmetrical. The client comes to a clinician for help and they often know little about the therapist. As a result the background is set for an attachment relationship to develop. In this context what the clinician does or does not do can ‘activate’ the attachment relationship, which will bring to the foreground how the client relates when they are in a help or support seeking mode. For example, emphasis on emotions rather than cognitions can activate the attachment relationship as well as the frequency of sessions and the overall length of therapy. The patient will likely be concerned with the therapist’s availability, both physical and emotional, exacerbated by separations between sessions, and emotional expression within sessions. However, because therapy involves boundaries and is an artificial relationship, Bowlby (1988) described the role of the therapist as being “analogous” to that of the mother, whereas Holmes (2010a: 57) speaks of a “quasi-secure base”. Allen (2012) stresses that the strength of the attachment relationship between therapist and client depends on the attachment history of both participants. Preoccupied clients may form intense relationships that involve dependence on the therapist; dismissing clients will treat the relationship as more of a coaching, consulting, or business relationship. Disorganised clients are likely to be very frightened and very hard to reach for long periods of time.

Consequently, an aspect of attachment informed psychotherapy is attention to the use the client is making of the therapist at any time. This can be intuited based on the client’s efforts to achieve closeness or distance. For instance, a client who is talking in a controlling way that does not easily allow for the therapist to participate in the dialogue may be understood as attempting to maintain the therapist’s attention and prevent the possibility of feeling ejected from the therapist’s mind. In contrast, a dismissing client may speak in a way that implicitly or explicitly undermines the therapist’s usefulness in order to prevent feeling dependent on the therapist. Disorganised clients may be so frightened of both intimacy and autonomy in their relationship with the therapist that they flip between the two modes of relating from session to session or within the same session. They can therefore be chaotic in the way that they affect the dyadic system they participate in .

  • Secure Clients. According to Allen (2012), these individuals are more likely to seek therapy, find it easier to form a working alliance, tend to experience the therapist as available and attuned, find self-disclosure more possible, and can discuss negative feelings in order to repair alliance ruptures. Secure clients display high mentalizing skills and appear to occupy a middle ground between autonomy and intimacy.
  • Dismissing clients. These clients are less likely to seek therapy, and find it harder to form a working alliance. They feel contempt for their vulnerability and are likely to feel critical towards the therapist as well as fearing criticism from the therapist. They prize autonomy, but struggle with intimacy. “Autonomous” individuals prize independence, freedom of action, privacy, and self-determination. When depressed, they are particularly sensitive to situations that they perceive as encroaching on their autonomy, mobility, or physical or mental functioning and respond with such thoughts as “I am defeated. I am incompetent. I will never be able to do what I need to do.” They are more likely to blame others for their problems although they are self-critical about their capacity to cope with situations.
  • Preoccupied clients. These clients are more likely to seek therapy and engage quickly in the working alliance, but this alliance can be fragile. They prize intimacy, but can easily feel disappointed and dread the development of their own autonomy. The alliance can therefore be unstable. For example, such a client can feel intense love and need for the attachment figure, but may also be very vigilant and irritable because of fear of rejection. There is a wish to be close, and an angry determination to hurt and punish the attachment figure if they are perceived to be abandoning, in the hope that this will prevent further abandonment (Holmes, 2014).
  • Disorganised Clients. These individuals can oscillate between the avoidant and ambivalent poles, showing stark switches between closeness and distance that can perhaps present in more extreme ways than the other two categories, ranging from complete detachment to terror of being abused in the therapy relationship.

Therapist attachment patterns – Wallin

Wallin (2007) has been influential in engaging with the consequences of psychotherapist attachment patterns, although references to these topics emerge in the work of other authors (e.g. Allen, 2012).

  • Secure therapists. They are more likely to be flexible and respond in a sensitive way to different client presentations. They can tolerate uncertainty well and are less likely to personalise clients’ responses to them. If they are caught in an enactment they can more readily begin to think about it and encourage repair.
  • Dismissing therapists. They are more likely to feel uncomfortable with expressions of intimacy, vulnerability and discomfort and less “porous” in experiencing the client’s affects, being possibly less able to empathise, although potentially more able to focus on the client’s mind. The may find dismissing clients hard and may unduly encourage dismissing clients’ autonomy at the expense of making emotional contact with them.
  • Preoccupied therapists. They are more likely to feel uncomfortable with distance and rejection, and are more porous to the client’s affects, being more able to empathise, but potentially at the expense of becoming overwhelmed and focusing on their own minds instead of their clients’. They may therefore find it hard to encourage clients to take a thinking position, avoid confrontation and be over-reassuring because they may see firmness as cruelty.
  • Disorganised / unresolved therapists. Wallin (2007) appears to assume that these do not exist or won’t be practising.

The relational school and attachment theory

This is an example where the body of theory and practice influenced and inspired by attachment theory is even wider and broader than attachment theory itself. Many believe that relational ways of working have been the most important overall new development in psychotherapy in the past 30 years. This is not the place to describe the basics of relational psychotherapy – in fact Confer has devoted a whole module to this subject.

Stephen Mitchell, until his untimely death one of the main forces in relational thinking, referred in many of his works to attachment theory. This is evident from the very early and prescient pages devoted to Bowlby in Greenberg & Mitchell (1983), his major article about attachment theory in Psychoanalytic Dialogues, Mitchell (1999), and to part of the subtitle of his last book, Mitchell (2000).

Lewis Aron refers several times to the importance of attachment patterns in his long interview with Safran (2009), and in a major article about new developments in psychoanalytic practice (Aron, 2000) covers similar ground to that in this study aid, placing both attachment theory and metallisation theory in a wider framework.

One of the essences of relational working is having a two-person instead of a one-person view of the therapeutic relationship. One could say that this sensibility of believing that both participants are equally important in the contact, and the importance of attainment between therapist and client, directly go back to the extreme attention paid to the mother (primary caregiver) – infant relationship in the pre-verbal period of the infant.