Promoting Secure Attachment Status in Therapy

One more way that life’s not fair: The people who need it the most get it the least – it being relationship support in the context of therapy. We know that relationship support can help people to tolerate pain, and a good therapy relationship can help the therapy client to tolerate emotional pain within the therapy, such as may occur during trauma work. But those who do not have secure attachment status are less able to access the therapy relationship support, even though – and precisely because – they are more in need of it (Muller, 2011).

The focus on attachment has become more mainstream in psychotherapy, especially among trauma-oriented therapists. The goal is to assist certain clients in achieving secure attachment status, which occurs naturally during early childhood for much of the population, or can later be “earned” via healing relationships. People with secure attachment status tend to be more resilient in the face of potentially traumatic stressors (Muller, Sicoli, & Lemieux, 2000), which is not surprising because secure attachment comes with a repertoire of coping skills, as well as a likelihood of having healthier relationships and thus better social support. Furthermore, those with less than secure attachment status tend to be less responsive to trauma treatment (Muller & Rosenkranz, 2009; Stalker, Gebotys, & Harper, 2005).

Non-Secure Attachment Status

Clients who are already securely attached do not need to work on their attachment status. How do you know which clients might benefit from attachment work? Characteristics that could indicate less-than-secure attachment include:
•    poor affect tolerance
•    instability in relationships
•    absence of close friendships
•    absence of intimate love relationships
•    black-and-white views of specific relationships (no tolerance for ambivalence or feeling different ways about the same person)
•    idealization of parents (all good or all bad)
•    a history of parents who were not able to provide consistent care in some important way (whether practical, material or psychological)

How to Promote Secure Attachment Status

Much has been written about helping children to become more securely attached. This can be an entire treatment approach in itself (e.g., Blaustein & Kinniburgh, 2010; James, 1994; Jernberg & Booth, 2009; Lieberman & Van Horn, 2011). In broad outline, this typically begins with providing a stable, secure, and nurturing environment. Then the parent is guided to engage the child in eye contact, nurturing physical contact (e.g., brushing hair), feeding, attunement play (in which the parent follows the child’s lead), and other activities designed to foster attachment. The child is also trained in self-soothing and other coping skills, and encouraged to achieve a series of competencies in which the parent takes visible pleasure.

With adults, the corrective relationship approach focuses on how to facilitate earned secure attachment within the therapy relationship (e.g., Kinsler, 2018; Muller, 2011) – again a comprehensive treatment approach. The Developmental Needs Meeting Strategy (Schmidt, 2004; Schmidt & Hernandez, 2007) guides clients to mobilize nurturing and protective parts of the self to meet the emotional needs of wounded child parts of self — which can lead to the healing of attachment-related wounds. The trauma healing strategy views the problematic attachment status as resulting from a cluster of “small T” or minor traumatic events that cumulatively caused the attachment wound, and treats this cluster of memories with a trauma resolution method such as EMDR (e.g., Wesselmann & Potter, 2009).

One widely used strategy is guided visualizations directly targeting the client’s attachment status; these have not yet been formally tested. The visualizations can be used in conjunction with any of the other approaches. The intervention featured in my recent book (Greenwald, 2013) is a visualization of a series of imagined early-childhood experiences of the type that would be expected to lead to secure attachment (being fed, being put to sleep, being comforted, etc.). Repeated practice of the visualization provides the brain repeated “experiences” of events that, hopefully and over time, contribute to a more secure attachment status. There are several variants of this type of visualization approach (e.g., Brown & Elliott, 2016; Steele, 2007), none of which has been researched (to the best of my knowledge).

Another prominent attachment-facilitative visualization intervention is Dyadic Resourcing (Manfield, 2010). This method involves having the client visualize a single image of interacting with an (imagined) attachment figure. Dyadic Resourcing has a more nuanced methodology and seems to achieve results with a single instance of the intervention, rather than by the repetition relied upon by the other visualization methods.

It is notoriously difficult to research attachment-facilitative interventions because the only really good assessment for attachment is notoriously resource-intensive. Even so, given the value of assisting therapy clients in developing a more secure attachment status – so they can better succeed in therapy and in life – such research is important to conduct. And meanwhile, trauma-oriented therapists remain keenly interested in promoting secure attachment status among their clients.

References

Blaustein, M. E., & Kinniburgh, K. M. (2010). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation, and competency. New York: Guilford.

Brown, D. P., & Elliott, D. S. (2016). Attachment disturbances in adults: Treatment for comprehensive repair. NY: Norton.

Greenwald, R. (2013). Progressive counting within a phase model of trauma-informed treatment. New York: Routledge.

James, B. (1994). Handbook for treatment of attachment – trauma problems in children. New York: Free Press.

Jernberg, A. M., & Booth, P. B. (2009). Theraplay: Helping parents and children build better relationships through attachment-based play, 3rd Edition. San Francisco: Jossey-Bass.

Kinsler, P. E. (2018). Complex psychological trauma: The centrality of relationship. NY: Routledge.

Lieberman, A. F., & Van Horn, P. (2011). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. NY: Guilford.

Manfield, P. (2010). Dyadic resourcing: Creating a foundation for processing trauma. Charleston, SC: CreateSpace.

Muller, R. T. (2011). Trauma and the avoidant client: Attachment-based strategies for healing. NY: Norton.

Muller, R. T., & Rosenkranz, S. E. (2009). Attachment and treatment response among adults in inpatient treatment for posttraumatic stress disorder. Psychotherapy: Theory, Research, Practice, Training, 46, 82-96.

Muller, R. T., Sicoli, L. A., & Lemieux, K. (2000). Relationship between attachment style and posttraumatic stress symptomatology among adults who report the experience of childhood abuse. Journal of Traumatic Stress, 13, 321–332.

Schmidt, S.J. (2004) Developmental Needs Meeting Strategy: A New Treatment Approach Applied to Dissociative Identity Disorder. Journal of Trauma and Dissociation, 5, 55-78.

Schmidt, S.J., & Hernandez, A. (2007). The Developmental Needs Meeting Strategy: Eight case studies. Traumatology, 13, 27-48.

Solomon, M. F., & Siegel, D. J. (Eds.) (2003). Healing trauma: Attachment, mind, body, and brain. New York: Norton.

Stalker, C. A., Gebotys, R., & Harper K. (2005). Insecure attachment as a predictor of outcome following inpatient trauma treatment for women survivors of childhood abuse. Bulletin of the Menninger Clinic, 69, 137-156.

Steele, A. (2007). Developing a secure self: An attachment-based approach to adult psychotherapy. Gabriola, BC: Author.

Wesselmann, D., & Potter, A. E. (2009). Change in adult attachment status following treatment with EMDR: Three case studies. Journal of EMDR Practice and Research, 3, 178-191.