Tailoring AEDP Interventions to Attachment Style
By Karen Pando-Mars
Abstract. Accelerated Experiential Dynamic Psychotherapy (AEDP) is an attachment-based, experiential and transformational treatment model whose theory, procedures and maps are ideally suited to address and treat relational trauma, which often underlies the motivation of patients to seek psychotherapy. AEDP’s therapeutic stance is one that employs corrective emotional and relational experiences to help patients know they exist in the heart and mind of another. Yet, to enter this kind of explicit relationship can be daunting for patients with insecure attachment styles, whose adaptive strategies become defensive shields to protect them from further relational wounding. This can be challenging for the therapist and patient alike. This paper is part of a larger project on how to differentially apply AEDP’s comprehensive model to treat attachment wounding, given the distinct formations of each attachment style. The paper starts with a brief summary of attachment theory and styles, and how AEDP applies and adapts the theory to therapeutic work. The grids I developed are then introduced to help match defenses and interventions to attachment style, to help orient and guide the therapist. The first grid shows detailed configurations of defense and affect regulation strategies for each attachment style. The second grid identifies the configuration of secure attachment as applied to the psychotherapy relationship. The third grid identifies specific interventions and targets specific goals to mobilize optimal transformations for each style. Here, transcripts illustrate how these AEDP interventions can be optimally attuned to patient attachment style.
The first time I introduced attachment styles and working with attachment in an AEDP Essential Skills course, the question came, “But what do you do with the patients who have these different attachment styles?” That question and others like it launched me to undertake this project of tailoring treatment to meet the distinct presentations of each attachment style. Excited to inquire phenomenologically, I set out to explore what I was doing in the process of treatment with my patients. This paper is the net result of studying each attachment style’s specific and contrasting elements. It remains a work in progress.
AEDP’s comprehensive theory is a profound match for the healing of the relational trauma that underlies insecure attachment. The AEDP therapist is theoretically poised and methodically trained to build a secure attachment in the therapeutic relationship, which provides an essential base for treatment (Bowlby, 1988; Fosha, 2000). Sometimes, however, a patient’s capacity for security does not easily come online and we find ourselves in the domain of insecure attachment patterns. This paper is designed to address these challenges by bringing greater precision to the understanding of the whole composition of each attachment style. In this paper I will first provide a brief summary of attachment theory and styles, and how AEDP adapts attachment theory and interpersonal neurobiology to psychotherapy practice. I will then discuss the challenges for therapists when insecure attachment shows up in the therapy room, and present the grids to help understand what’s happening and provide a compare/contrast among attachment styles. Lastly, I will explicate interventions tailored to each attachment style, with transcripts of videotape illustrations.[1] My overall intention is to show that when the clinician addresses the particular needs of patients that are paramount to each attachment strategy, treatment can mobilize the specific transformations needed to bring about their “earned secure attachment” [2] (Siegel, 1999).
BOWLBY AND ATTACHMENT THEORY
Attachment theory has its roots in animal studies, i.e., ethology. When John Bowlby was seeking to understand the profound impact of maternal loss and deprivation on young children, he was introduced to and inspired by Konrad Lorentz’s work on how ducks imprint (Bowlby, 1988; Parkes et al., 1991). His studies led him to see how the bond of attachment serves humans across their lifetime. He is known for saying, “Attachment operates from the cradle to the grave,” meaning that human beings need relationships with others throughout our whole lives. We are social creatures and our nervous systems are designed to see and be seen, to care and be cared for, and to participate and belong to family and social groups with others (Adler, 2002; Cozolino, 2006).
Bowlby identified three behavioral systems of attachment: the attachment system, the caregiving system and the exploratory system. Young beings engage the attachment behavioral system when they are in pain, fatigued or frightened or if the mother appears to be inaccessible. This proximity brings protection and thus provides a “secure haven.” The caregiving behavioral system (parenting) refers to that aspect of the attachment relationship in which the mother responds to the child’s needs, providing comfort in times of distress and reassurance in times of fear. With these in place, a child has a “secure base” from which they can explore the world, developing “the exploratory behavioral system” (Bowlby, 1982).
Bowlby also developed the construct of the internal working model, the way the relationship between child and caregiver is internally represented (Bowlby, 1969, 1973). In the achievement of a secure attachment bond, when one’s caregivers are sensitive and responsive, the “Other,” i.e., the caregiver, is represented as responsible and reliable, and the “Self” feels protected, worthy and secure (Ainsworth, 1978). Someone with a secure attachment has an internal template for relationship that represents others as capable and willing to respond, and one’s own self as worthy of response. This brings about trusting and seeking proximity and help in times of need to be a natural experience. Bowlby (1988) has further postulated that psychotherapists can build both a safe haven and a safe base with patients, which allows them to feel safe in the relationship and to explore the necessary memories and experiences that need attention and healing in psychotherapy.
When she joined Bowlby at the Tavistock Clinic, Mary Ainsworth developed the “The Strange Situation” as a prototype for attachment research,[3] which led to the classification of attachment styles. Subsequently, her student Mary Main gathered data about those with inconsistent responses that did not fit into the existing classifications. Main and her colleagues identified this category that arises specifically in response to trauma as reflecting “disorganized attachment” and characterized its dilemma as being “fear without solution” (Main & Solomon, 1990). Main also developed the Adult Attachment Inventory (Main, 2000), and studied how the attachment styles and representations maintain across time and how the attachment style of each parent impacts the attachment style of the child in interaction with that parent (Main, Hesse, & Kaplan, 2005).
Role of Mentalization
Peter Fonagy has written extensively about the biological need to be understood and how we internalize others to build a sense of self. He has focused on the development of a reflective state of mind and identified this as mentalization: when a person has the capacity to think about their feelings and feel about their thoughts (Fonagy & Target, 1997). In describing how the reflective state of mind develops, Fonagy describes that when the internal world and the external world are equated, this is psychic equivalence: “how I think of myself matches what comes to me from outside of myself.” When the internal and external world decouple, this is the pretend mode: how I think about myself has no relationship to what presents in the outside world. Mentalization is the integration between these two modes.
“In normal development, the child integrates these two modes to arrive at the stage of mentalization—or reflective mode—in which states can be experienced as representations. Inner and outer reality can be seen as linked, yet they are accepted as differing in important ways and no longer have to be either equated or dissociated from each other” (Baron-Cohen, 1995; Gopnik, 1993; from Fonagy, 2005, p.57). In other words, with a developed reflective function, which is achieved in secure attachment, there is flexibility between how a person relates their internal world with external reality.
Fonagy also has identified the alien self, a representation of unresolved trauma, akin to an introject. The child internalizes the mind of another, which can be very disturbing when it erupts later in life. When this happens, the person’s felt experience is that this is “not me.” This becomes relevant to know with traumatized patients who have not received adequate mirroring and care, and subsequently lack a developed reflective capacity. Fonagy says: “Attachment theory shows us how a person’s sense of self emerges through their early bonds with caregivers, but that this is not an end in and of itself, but is part of how we develop a representational system that has evolved to aid human survival. That with secure attachment, we are able to know our own selves and are able to know and understand another” (Fonagy, 2005, p. 2). When a parent can hear and perceive the distress in their child’s cry and reliably respond with the specific help that is needed for that child in that moment, most often the child settles and receives the comfort that is offered. When this expression of their internal state is met by their parent’s response, the child can form a representation that their needs can be soothed by another. They are, in fact, soothable.
Interpersonal Neurobiology of Attachment
Allan Schore has contributed immensely to our understanding of affect regulation and right brain development, and how caregivers’ behavior with their children shapes how the children’s brains will mature to appraise, as well as respond to human communications. He also speaks about state-sharing in psychotherapy which addresses how our right-brain to right-brain communications with our patients are essential to promote growth and development. He states, “At the most essential level, the intersubjective work of psychotherapy is not defined by what the therapist does for the patient or says to the patient (left brain focus). The key mechanism is how to be with the patient, especially during affectively stressful moments (right brain focus)” (Schore, 2012, p. 44). This right-brain-to-right-brain accompaniment is an essential ingredient to providing corrective emotional and relational experiences by offering the deep “being with” that was absent at crucial times in a patient’s life.
Dan Siegel (2007, 2010) has integrated enormous amounts of interpersonal neurobiology as it applies to the practice of psychotherapy. His contributions articulate the development of the reflective mind and how mindfulness practice contributes to earned security. While Fonagy’s work makes clear how being understood leads to the development of a reflective mind, Siegel studies the neuroscience of the brain’s resonance circuits and explicates how the therapist’s mindful presence and responsiveness can help clients develop the specific parts of the brain that yield this capacity for reflective function (Siegel, 2009).
Fonagy established that it takes only one relationship with one understanding other for the impact of trauma to be transformed (Fonagy, 1995, from Fosha, 2000). Siegel’s recent work discusses the mind as an organizing process that regulates the flow of energy and information and expounds upon what happens in trauma and in health. In a state of trauma, there are many crossed wires, bundled circuits, where associative links trigger nervous system activation. Siegel emphasizes that when a person can identify their source of upset and can access their pre-frontal cortex to make understanding, they are creating linkages between different parts of the brain, which eases their disturbance (Siegel, 2007). This is ever so relevant to the healing of early attachment trauma and disorganization.
In gathering the essence of these contributors, it seems clear that what we psychotherapists have available to guide our interventions is paying close attention to our interactions with our patients and how they unfold. I want to remember that my patient was once a child who grew in the light and shadows of how his or her caregivers treated him or her. The way the caregiver attended the child’s nervous system arousal and recognized and responded to their emotion, formed the basis for how our patients now regulate their affect. When a child’s cues are heard and met with sensitive care, the child develops basic trust they can be met reliably and be understood. This helps the child to feel worthy and establishes a secure internal working model of self and other. Being seen, felt and understood forms the substructures of self- reflective capacity which matures into a deeper understanding of self and other that continues to evolve throughout the stages and seasons of life. However, when patients come into our psychotherapy offices for whom these early attachment needs have not been sufficiently met, our work begins, with all of this background in mind and heart.
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