Tailoring AEDP Interventions to Attachment Style (Page 3)

DEVELOPING THE ATTACHMENT STYLE GRIDS

As I began to explore how to intervene with sensitivity to each attachment style, common therapeutic obstacles and patterns related to attachment style began to emerge. I started by creating a visual grid to specify the behavioral markers under each attachment category (see section below and Figure 1). By studying the parts, I hoped to identify the whole configuration of each style’s coping strategy. I recorded what I noticed with different patients, i.e., what happened in the different sub-groupings of experience. I saw distinct and specific relational attitudes, patterns of arousal, affect regulation, defenses, and how these behavioral responses initially were adaptations to the behaviors of significant others in their lives. Over time, I refined and clarified the key items and categories into a template through which I could study the different constellations of each attachment style, and see the ways they compare and contrast with each other. I also created a grid for client patterns when there is secure attachment (see section below and Figure 2).

As I worked on these grids, I began to integrate how they fit the AEDP frame of self-at-best and self-at-worst (see footnote 4). In the AEDP model, one major thru-line of treatment is to work with the self-at-worst under the aegis of the self-at-best.  This is an AEDP phrase that emphasizes the importance of building a secure base first and foremost with our patients.  This foundation provides the safety and accompaniment necessary for exploration and generating new corrective experiences that can treat and heal old patterns of insecurity and trauma that resulted in these—seemingly—fixed and invariant patterns of each attachment style (Fosha, 2000; Bowlby, 1988; Mikulincer & Shaver, 2007). Once I established the first set of grids, I observed how I responded and intervened differently with each style, and then created the grid of interventions, which specifies differential treatment approaches for each attachment style (see section below and Figure 3).  The net result of these grids is having a tiller with which to steer treatment.

Grid I: Self-at-Worst in Therapy Per Attachment Style

In this grid, I identified characteristics of each insecure attachment style: avoidant, ambivalent and disorganized, and grouped them into subcategories as mentioned above. This can serve to orient psychotherapists as to what is actually going on with patients when psychotherapy seems challenging or the way seems blocked. Having some understanding of how arousal and affect regulatory patterning, for example, fits in witthe bigger picture of each attachment style, can inform clinical decision making by steerig treatment towards what is actually needed for each patient given how they developed.

Avoidant/Dismissive in Therapy

When the AEDP therapist draws explicit attention to the therapist-patient relationship, and this brings about dismissiveness, we are in the terrain of avoidant defenses.   Specifically, distance and withdrawal are defenses against relatedness, which work to break the connection to the attachment figure in an adaptive move to preserve the integrity of the self (Fosha, 2000).  If a person avoids interaction with the person who injures them, they prevent themselves from feeling hurt.  This is what underlies the above avoidant response to attention on the therapeutic relationship. The task of revealing oneself to a therapist can tap painful memories of not being seen and known by a caring other from a young age. Some of the usual ways the AEDP therapist intervenes to establish safety and undo aloneness, offering the possibility of relational accompaniment, can actually escalate the discomfort (arousal) and increase the defensive strategies in avoidant patients. With patients who have been self sufficient, and relied on their own instincts to get by, they may misinterpret the therapist’s affirmation as patronizing. Attempts to validate the patient can generate a reaction of irritation, confusion, or even blankness. The therapist’s well-intentioned interventions can bring about deactivating strategies as the patient shuts down his or her access to relationship needs.

Rather than exposing vulnerability, avoidants use these defenses against relatedness to provide protection from the feared and expected rejection, humiliation, disappointments, losses, intrusions and/or shaming. When a person has become accustomed to a lack of being seen and known by a significant other from a young age, they derive a sense of control from not needing.  Thus, deactivating when faced with potential vulnerability.  Defenses against emotion, such as shutting down and disconnecting, helped the person to manage being overwhelmed, suffering the aloneness, and feeling intense affects by disengaging or distracting from his helplessness at a time of need. Defenses against emotion break the connection to self, which was an adaptive move to preserve the attachment bond for big picture survival.

With avoidant patients, therapists may feel challenged and have a difficult time maintaining their own self-at-best when their comments are dismissed, ignored, or rendered pointless. Avoidants may be verbal and explicit with their dismissing words.  Or they may be less obvious but impactful by making gestures of brushing off or facial expressions of displeasure, disapproval or distain. Here it is important to notice how the dismissive actions effectively diminish the therapist’s movement towards relational or shared experience. As the avoidant may rely on overfunctioning in an intellectualized way, therapists might feel frustrated and ineffective when their efforts to engage meet the fixed stance of self-reliance.

Ambivalent/Preoccupied in Therapy

With ambivalent patients, their thoughts usually instigate the onset of feelings, but thought-driven feeling does not move in waves that arc and complete.  Rather, the intensity of oncoming thoughts drives the emotion with high levels of anxiety and no release, which is emotionality rather than emotion.  More aptly, defense against emotion, as the deep-seeded fear of abandonment leads to run-on sentences full of tangential thinking and fragmented themes. Often overlooked by caregivers, this person’s relationship to their own self has been untended, and now, stories of their own lack of deserving and unworthiness spin like a broken record. Only they do not notice the skip sound that repeats again and again, as their stories circulate building fears and anxieties in repetitive loops between their nervous system and tales predicting messages of doom.

While ambivalent patients are preoccupied, and very other-focused, they also have defenses against relatedness. They manifest in how these patients can have difficulty picking up relational cues and seeing the therapist as a separate person from them. There is often a sense of pent-up energy, spewing information, building a case about self or other. Yet they don’t seem to be really be listening to their selves, or expect to be heard. They are unable to process their own experiences, much less make use of their articulations. They have trouble making use of the therapist’s presence for connection and soothing. When hyper-activating strategies loom, the patient’s fear of abandonment and/or self-fragmentation may indeed ward off the kind of true engagement needed to quiet such desperation.

With ambivalent patients, facing preoccupied thinking and indirect expressions, therapists may feel overwhelmed and have a sense that control of the session has gotten away.  When therapists attempt to deepen affect, agitation can worsen as emotions are bundled, mixed with anxiety, and filled with unrealistic views of others and self. Focus is difficult to establish when subject after subject are thrust on the table in the effort to “get it all out first.” Here, notice how the preoccupied strategy functions as a defense against relatedness, as the constant digressing actually becomes a wall of words, with momentum that thwarts the therapist’s attempt to engage.  At the extreme, when the ambivalent displays their frantic need for attention and help, the therapist can feel pulled under by the flailing of unboundaried anxiety.

Disorganization/Unresolved in therapy

With disorganized patients, who have unresolved trauma, their narrative comes out in incomplete expression (Main, 2000) and may not hold together in a coherent way. Their presentation may be disoriented, confused, or stories may tumble out in succession. Affect may not match what is expressed verbally. Emotion and memory are often disconnected. Young parts of self are often abandoned without explicit memories, yet their implicit (unconscious) memories are often driving their reflexive behavior. Many times, these patients describe being in relationships where they are being mistreated or they are mistreating others. Emotions sometimes erupt without predictable provocation.  People who generally display organized secure, insecure avoidant, or insecure ambivalent attachment styles can also become disorganized when unresolved trauma is triggered.

In disorganized states, defenses against emotion appear with dissociation, displacement and numbness. Affective parts of self have been splintered off, locked up, stored in such images as a beaten-down dog or a forlorn child. Sometimes these parts of self are despised and hated. Utterings can be incomplete. During the therapy hour, approaching these dissociated parts can provoke cognitive disruption and loss of focus. Defenses against relatedness show up in a patient’s struggles with issues of power and control.  Patients can appear, and even be, threatening to self or other.  They may take on a pathetic voice of submission or a domineering voice of control. States of trusting the therapist can slip into states of pathogenic affects when the patient drops into deep shame, or unbearable aloneness.  Patients can become immobilized, caught by attacks against self yet unable to reach or be reached by the therapist.

Sometimes, the disorganization can appear to move and settle into something more organized as one part of the person convincingly steps forward. Here, the therapist might inadvertently support the apparent strength (or whatever aspect appears) of one part without realizing that this may be a compensatory expression, and that a counterpart might be close behind. This can be quite disconcerting for the therapist when the following week an opposing part arrives to session in a reactive mode, with a whole new set of issues. The therapist can be daunted by the backlash, a seeming undoing, when a different part surfaces after a piece of work that had seemed to move the process in a “positive” direction.

With disorganization, therapists may find themselves confused about what is significant in these inchoate, fragmented ideas or actions that seem to be non-sequiturs.  Sometimes metaprocessing questions are met with blank stares or dissociation, as the self-reflective capacity is underdeveloped.[7] The therapeutic relationship can also be dicey when working with clients whose role reversal was in response to parents with unresolved trauma. Therapists may find themselves challenged to stay clear in their perceived role as an older, wiser other to patients for whom the parent-child relationship has switched upside-down in early life.

When therapists are working to build secure attachment and their patient’s self-at-worst behaviors fail to budge, it can be orienting to realize this is the realm of insecurity of attachment, disorganization, and the different styles they manifest in.  Since these once adaptive, now defensive, strategies appear at the intersection of emotion and relatedness, it behooves psychotherapists to pay attention to how we intervene—and when—given that what can be helpful and regulating for one patient may actually be triggering and dysregulating for another.

Figure 1: Self-at-Worst Configuration within Each Insecure Attachment Style

As we look at the procedural learning that comprises insecure attachment, it is important to define what happens when secure attachment manifests (Figure 2). This can serve us in two ways. It will help us recognize the patterns of secure attachment when they appear in our patients, and it will help us to identify the specific ways in which we can be ourselves, and attune to each of our patients to evoke security and assist them to feel welcome and in the right place from the get-go and throughout.

The self-at-best is the sense of security that shows up when the therapist can access a reflective state of mind and a heart of good will, especially helpful when the therapy is stuck. It is the capacity to provide help to our patients in the way they can receive, with respectful inquiry that engages a spirit of collaboration. With a flexible capacity to engage—by having a sense of one’s own experience and the experience of the patient—the therapist can address obstacles as they appear in the therapy. Whether there is a disruption in the therapeutic relationship or an activation of the patient’s nervous system from an earlier trauma, the characteristics that make up self-at-best serve the therapist to meet the patient in the most specific way possible for that patient in that moment with the sensitivity and responsiveness required. For example, if the patient feels doubt in me or suddenly a lack of safety arises, I do not have to insist that I am trustworthy. But rather, I can trust something important is emerging, despite the fact that this development seems to knock out the very trust in our relationship that we have been so meticulous to nurture. Even when the ground beneath us appears shaky, and shadows of the unbearable are lurking, I can strive to maintain a steady presence with my patient, with interest, faith and invitation to meet whatever is happening.  My presence and willingness are important at the threshold of what grips my patient.  With consistency and successful navigation, these fallouts become opportunities for building strength in the therapeutic alliance.  In time this can help bring some of the patient’s self-at-best back online, so that instead of further demoralization, together we can face the demons, process what is needed for the patient to find and reconnect with vital, essential forces that were severed at crucial moments of pivotal life experiences.
As previously discussed, AEDP’s theoretical base provides theory, skill sets and interventions pathways designed to maximize the potential for self-at-best to come online for patient and therapist alike.  Grid 2 summarizes this secure configuration to provide a compare /contrast with markers of insecure attachment styles as well.

Figure 2: The Self-at-Best Configuration within Secure Attachment

INTERVENTIONS TAILORED TO EACH ATTACHMENT STYLE

The obstacle is the lever.

from The Mother by Satprem (1982)

In the following sections, I will expand the points in Figure 3 and show the ways I intervene to meet the specific attachment-shaped needs of the patient in front of me.  While the interventions in and of themselves may not appear so different, closely understood and unpacked, they are. The intention, manner and the sensitivity with which I seek to respond to their impact is an important part of tailoring treatment to the manifestations of the attachment style of that particular patient. After all, building security is the underlying need that is common to all. As Diana Fosha has said, “the unit of intervention is not the therapist’s comment, but the therapist’s comment and the patient’s response” (Fosha 2000, p. 214). And, in turn, the patient’s response is what determines the therapist’s next intervention. Depending on the precise nature—verbal and non-verbal—of my patient’s response to the intervention I just made, I consider what is the actual right next step for each patient. This involves attuning to their regulatory needs and capacity to work with me as an trustworthy ally, or accompanying other; or alternately, realizing that they are needing some space while questioning whether or not they dare take a risk.

As I begin the work of articulating interventions, I will continue to hold the AEDP three-stranded braid of relatedness, emotion and transformation. I am just as interested in leaning into emergent signs of health, as I am at transforming outdated strategies of protection. As we know, old patterns die hard. For this reason, I find AEDP’s articulation of transformance strivings a brilliant gift to give our patients who are so threatened by what happened to them at a young age, and so determined to prevent it from happening again at any cost. When therapists can identify the resilient features of their patients’ strategies and help them to augment these ways by affirming and leaning in, with just the right dose of attention and staying power, the going gets easier. My emphasis is that what to lean into changes depending on who is in front of me, so first, I want to attune, and second, I can aim to choose the pathway that I hope will be most helpful.

Figure 3: Interventions Tailored to each Attachment Style

If my heart could do my thinking

And my head begin to feel

I would look upon the world anew

And know what’s truly real.    

                              Van Morrison

Avoidant/dismissive

With avoidant patients, I have come to see that the focal goal of treatment is to harness relational action tendencies. These are a) being open to the giving and receiving of attention and empathy to another; b) feeling close, moved, and tender with another; and c) recognition of one’s own needs and the needs of others (Fosha, 2000). This incorporates building connection to self, which ultimately can include allowing early memories, and recognition of unmet longings, to emerge. Herein develops the capacity to empathize with others, by first healing their own impoverishment in the realm of relationships. This begins in the therapeutic relationship as the therapist shows up as a reliable other on whom the patient can begin to lean and learn how to connect to his emotional life. While the avoidant has come to self-reliance as a primary modus operandi, what they rely on in themselves tends to be determined by thoughts. Their capacity to value somatic and emotional avenues of expression is relatively narrow. Questions about what is happening in their bodies are met with blank stares, a shrug of the shoulders, an eyebrow raised in confusion: What does that have to do with anything?

When the therapist approaches any expansion of the avoidant’s repertoire, the likelihood of being met with a defensive response is predictable. It is important to understand how dismissiveness to the best intentions of the therapist operates reflexively and automatically. When the dismissiveness comes implicitly through a subtle wave of the hand or turn away of the head, this message can be a powerful derailer. Therapists may have to expand their own internal working models in order to perceive fully the impact, when encountering this defensive, implicit, non-verbal information.

The therapist can begin by initiating a respectful exploration with patients who have survived in life by pulling themselves up by their own bootstraps, so to speak, using these very strategies. Bringing a patient’s attention to bear on their awkward discomfort, and explicitly noting that this is uncharted territory, can sometimes alleviate some of the distress by sharing information about what may be an unknown experience. Here, when the AEDP therapist can employ the classic making the implicit explicit, with curiosity and collaboration, treatment has more potential to gain traction.

With avoidant patients especially, I am struck anew with what a courageous act seeking therapy can be and how we need to be sensitized to the delicacy of reflecting this transformance drive to an avoidant in a non-triggering way.  The avoidant has often achieved significant accomplishments, without much acknowledgment and attention from significant others.  The direction here is to notice what happens with contact, to find a window of tolerance, aiming for just enough activation to supply some energy to have a new experience (up-regulate), but not so much arousal as to bring about becoming overwhelmed, defensive shutting down, aggressive reactivity or rejection of the treatment.

Feel into Thoughts, Images, Affect-laden Words

The best interventions are always those which are already trying
to happen. (Mindell & Mindell, 1992)

If an avoidant has responded to a question by telling a story, I can notice whether or not they are answering the question, or I can stay with the patient and listen for the response in the narrative and then have them feel into a thought they just shared. I might focus on an affect-laden word or sensation or imagery. Sometimes with such patients, images come more easily than feelings. In fact, many alexithymics who are perplexed about emotion will share an image. When I notice my patient is spontaneously using an image, I will ask for focus on what they are seeing. In this way, I can highlight something that is already happening to help the avoidant pay attention to what is in the background (implicit) and bring it into the foreground (explicit) of their awareness. By receiving the story, noticing an image and reflecting back an affect-laden word, I accept what the patient shares. This counters anticipated rejection from another or worries about not being enough from the self. I help the patient to hear, see and notice their own emphasis, which is a way to build their connection to self and their capacity to register experience while in my presence.

With many avoidant patients, inquiring about what is happening inside, in their bodies, brings a disgruntled response. This can be a reaction to what is interpreted as a criticism. Or perhaps I am actually asking for something about which the patient has no awareness (and thus has no capacity to respond). The deflection from such inquiries serves to protect the person from the risk of vulnerability or being seen as inept.

Naming something I observe assists the patient locate where to focus, so that they can have a sense of ownership in the exploration. Mirroring what is already happening bridges the gap between making contact and finding words. In this way, the distance between that which is revealing itself, but is not yet known or realized, can be navigated with the therapist’s caring attention to each stirring emergence. This kind of reflection builds a collaborative stance that amplifies the senses, and invites the self to take notice and become curious.

Amplify Glimmers of Core Affective Experience

When interactive mirroring and delight are absent, unreflected aspects of the self remain unformed areas of experience. (Fosha, 2013)

When I am therapist to an avoidant, for whom emotional vulnerability is sealed off, I am aware of searching for the young one who was neglected, rejected, given little or no attention.  Lack of attention becomes a lack of knowing how to attend to the self, to the needs and emotions of everyday life. There is a profound stillness of being that resides in the quiet of loneliness, in the emptiness of hours spent without engaged, loving presence. This is what I reach for, as a therapist with my heart engaged. I am listening for the rustling of an adapted younger self who struggles with doubt in the midst of knowing “I can do”, while the doing “on my own” has left such a void.

Approaching the experience of affect and emotion can be fraught as the entry requested taps the very void that was neglected. Here it is so important for the therapist to remember that someone with a dismissive strategy uses this defense for an adaptive reason. At best, emotional experience wasn’t noticed, and at worst it was met with hostility, criticism or rejection. To approach this terrain is to venture into the circuitry of the nervous system that is hardwired to deactivate, to disengage from risk of being hurt. The challenge here is caught so aptly by RD Laing, who said, “We are unaware that there is anything of which we needed to be unaware, and then unaware that we needed to be unaware of needing to be unaware” (Laing, 1969, from Bromberg, 2011, p. 31).  This is tricky indeed with an avoidant – to bring awareness to something where so many layers of disengagement cover the more vulnerable self.

For this reason, I find it very important to notice and accept the channel of experience (Mars, 2011) that opens. When early emotions have been disavowed, other channels have an easier time coming online. Some avoidants will shake their heads (movement channel) at the request to describe what they are feeling.  And yet, they might identify an energetic flow with their marital partner when a back and forth exchange leads to satisfaction for both of them.  To receive this communication as significant is so important. Here we are countering the sensitivity to rejection and shame, and making sure to receive the way the patient responds to our bid for affective communication.
Sometimes expression of experience comes through gestures. By asking our patient to repeat and/or amplify their movement, I can often help them notice and be with the gesture, which can facilitate connection to its underlying affect and potentially reveal a body-based affective memory.  This brings connection to early life experience and the roots of relational experience; and to prove the cliché, actions speak louder than words. Contact in this way reaches below the thinking mind, and from here there is often an easier process of linking procedural learning to problems in relationship, and increases awareness of customary defensive and protective reactions.

For some, merely being seen is activating, as not being seen has been the refuge. I have one avoidant patient who cringes when I notice signals of his tapping fingers or jiggling feet. At this point when he sees me seeing him, he blushes, grits his teeth and makes a kinds of “shucks” sound. He tells me he feels unsuccessful, that my seeing him is evidence of the failure of his intention to be unreadable and thereby unflappable. While this may be his best option in his business negotiations (the “ole poker face”) we are playing with the potential that visibility and transparency between him and his wife, while breaking all the rules, might possibly lead to some fun and affection. With him, humor has been my ally and a place we can meet.

Build Receptive Affective Capacity

When a therapist dares to tread into the territory of inquiring about how the patient is receiving the therapist’s attention, help or care, the result can be mixed and relational interventions can be suspect. Not needing anyone is the procedural learning that underlies these defenses. When the therapist offers to help, the patient may have difficulty receiving the offer, as it would seem to undermine the defense structure as a whole. “If you are offering me help, you must see me as needing help – which is intolerable.” Herein lies a catch 22.  Or, “If I let you see me, for sure you will later reject me and I would attack myself for being a fool and bringing on that pain … In fact, I won’t be vulnerable at all, for that is dangerous … Better to hide behind my wall and suffer in silence.” It takes the persistent, respecting inquiring attention of the therapist to draw out the protect-at-any-cost rules of the patient’s internal working model. The therapist needs to help the client notice what is different in the here and now, which takes sensitivity on the part of the therapist to titrate the attention and give the avoidant the space from which to approach the therapist and see for themselves. The intention is for the present experience with the therapist to disconfirm the certainty of those expected responses (Ecker, 2012).

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