Below you can read a case study of an individual with an avoidant attachment style, one of the more difficult attachment styles to work with in therapy.

Case Summary

Daniel has presented with a story that would on the surface indicate a dismissing/avoidant attachment style (see Appendix A). The key clues being Daniel’s reported inability to have a satisfying intimate relationship, and that “relationships are potentially dangerous and painful”. These remarks suggest an avoidant style as these individuals “minimise the importance of social relationships and downregulate affect” (Bucci, Seymour-Hyde, Harris, & Berry, 2015, p. 162), even going so far as to avoid close relationships (Bartholomew & Horowitz, 1991).

However we should be cautious. The extreme brevity of the case profile, some features of his past (according to Hobson, Patrick, Crandell, García-Pérez, & Lee, 2005 up to 80% of infants of a BPD mother show disorganised attachment) and some contraindications in the profile language (Daniel’s reporting “ongoing hurt” is not consistent with an avoidant attachment style who prefer, as noted earlier, to downregulate affect) must allow for the possibility that Daniel has another style (disorganised) and further assessment would be necessary to confirm his style. It is possible that Daniel’s reporting that relationships are dangerous and painful is a view formed as the result of the experience of failed relationships rather than his attachment informed belief about relationships.

In other words, further assessment to confirm Daniel’s attachment style would be ideal. However, working with the confines of the profile given, and for the purposes of this essay, it will be assumed that Daniel has an avoidant style.

Avoidant attachment

The avoidant individual goes through life with “a profound belief that you have to stand on your own two feet, that seeking help is a form of weakness, [and] that strong emotions should be avoided, particularly upsetting negative ones” (Cundy, 2018, p. 1). It is easy to see how such deeply held beliefs work against satisfying social relationships, particularly intimate ones as reported by Daniel.

But what are these beliefs really and where do they come from?

Arising from the work of John Bowlby (1969, 1973, 1980) attachment theory posits that infants are born with behaviours such as crying and clinging developed through evolution to ensure proximity to supportive others in times of need. Attachment to another increases the infant’s chances of survival. Where there are positive interactions with available, sensitive and responsive caregivers the infant develops “a sense that one can rely on close relationship partners for protection and support, can safely and effectively explore the environment and can engaged effectively with other people” (Mikulincer & Shaver, 2004, p. 159).

Where however an attachment figure has not been reliable and supportive this sense of security is not attained by the infant. “Doubts about one’s lovability and worries about other’s motives and intentions are raised and affect regulation strategies other than healthy proximity seeking are formed ie secondary attachment strategies characterized by anxiety and avoidance.” (Mikulciner, Shaver & Berant, 2013).

Bowlby explained what happened to the avoidant infant. The avoidant, he said, is:

…someone who is readily plunged into prolonged moods of hopelessness and helplessness, has been exposed repeatedly during infancy and childhood to situations in which his attempts to influence his parents to give him more time, affection and understanding have met with nothing but rebuff and punishment. (Bowlby, 1979, p. 158).

As Graham Music puts it, the avoidant is “marked out not by what happened to them, but rather by what did not happen to them – in other words, neglect.” (Cundy, 2018, p. 3)  In light of this neglect or rebuff and punishment by a persistently non-reciprocal, disparaging or dismissive caregiver, it is understandable then that individual adapted their behaviour to avoid their core attachment wound of feeling unwanted (Cundy, 2018, p. 38). This adaptation allows the individual to show, themselves and others, that they are independent or as Bowlby put it “compulsively self-reliant” (Bowlby, 1982).

This self reliance allows the avoidant to say to the world: I don’t need others (Tatkin, 2009, p. 13). Really, what the avoidant is doing is compromising. They compromise in order to achieve some measure of proximity to the neglectful caregiver. “In these families the best chance of care came to children who could defensively exclude their desire for closeness and comfort” (Cundy, 2018, p. 39). Defensively. That is a key concept in understanding the insecurely attached, including the avoidant, generally. The avoidant individual creates defences or what Mary Main (1990) called deactivating strategies to protect themselves.

Coming to believe therefore that others cannot be depended on, the avoidant individual defensively becomes self-reliant and forms a view of themselves as independent: Stand on your own two feet… They tend to devalue experiences of intimacy, closeness, and vulnerability (Muller, 2010). The avoidant fears a repeat of their original rejection and has “enormous difficulty trusting others enough to be genuinely intimate with them” (Wallin, 2007, p. 211) and will minimize feelings associated with attachment experiences often idealizing, though sometimes disparaging, their caregivers (Wallin, 2007, p. 218).

These defences against intimacy understandably then make intimate relationships very hard for the avoidant individual, as we see in Daniel.

 

 

Treatment plan

Summary of client issues

Daniel reports that

·      he is unable to have a satisfying intimate relationship

·      “relationships are potentially dangerous and painful”

·      ongoing feelings of hurt towards his mother

Client’s attachment style

The client’s avoidant attachment style is evidenced by:

·      his self-reported difficulty having satisfying intimate relationships and that he finds them painful and dangerous. As noted earlier by Bucci et al (2015), the avoidant will “minimise the importance of social relationships” and even go so far as to avoid relationships (Bartholomew & Horowitz, 1991).

·       his parents both having traumatic childhoods. This is relevant for two reasons. Firstly, childhood trauma significantly predicts insecure attachment style (Fuchshuber, Hiebler-Ragger, Kresse, Kapfhammer, & Unterrainer, 2019). So we can assume then Daniel’s parents both had an insecure attachment style. Secondly, parent’s attachment styles are strongly correlated with their child’s (Verhage et al., 2016). It is thought a correlation exists because parental attachment styles influence the sensitivity of their interaction with their children (Moullin, Waldfogel, & Washbrook, 2018).

·       his mother’s BPD impacting her ability to attune to Daniel as an infant and also to reject him. Psychoanalyst Donald Winnicot championed the idea that caregiver attunement to an infant is critical for the development of a sense of security, and therefore a lack of attunement is likely to lead to a sense of insecurity (Van der Kolk, 2014, p. 130).  

·       His mother’s BPD splitting defence mechanism, where people are seen as either all good or all bad, made her favour Daniel’s brother, increasing Daniel’s sense of rejection (Pec, Bob, & Raboch, 2014).

·       his father abandoning the family leaving Daniel again feel “utterly alone”. Daniel was again rejected by an attachment figure.

Formation, maintenance and termination of the therapeutic relationship with this client

The therapeutic relationship would need to work towards developing Daniel’s sense of safety and acceptance. Avoidants generally, and Daniel particularly (having been rejected by both attachment figures), need to feel safe, accepted and trusting enough to learn a new message: “that one can rely on close relationship partners for protection and support, can safely and effectively explore the environment and can engaged effectively with other people” (Mikulincer & Shaver, 2004, p. 159). The issue of course is that avoidants have come to distrust others and rely only on themselves. Therapy then needs to find a way to allow the client to trust in others.

Formation. The early stages of therapy need to put a particular focus on keeping Daniel feeling safe. This may include favouring cognitive discussion over affective exploration, a sense of empathy, minimal challenges to his narrative, and particularly ensuring Daniel does not feel trapped in therapy including by developing his own motivation to continue with therapy (Muller, 2010). The therapist could state a desire to help but stress his respect for Daniel and his right to decide whether to continue.

Maintenance. After Daniel’s trust and some sense of safety has been earnt, we can move into the real work where Daniel’s defensive avoidance is challenged. This must be a slow and finely balanced process to avoid going too far and making Daniel feel unsafe again.

Termination. Terminating the relationship with Daniel would need to be done collaboratively with particular consideration given to Daniel not perceiving he is being rejected again. Greenberg (2002) outlined a comprehensive set of principles for terminating treatment. Effective therapy may have given Daniel the earned security to see the end of the relationship not as yet another rejection of him personally but for what it actually was, the end of a professional relationship.

Client’s therapeutic goals

·       At first session: 1) Enjoy satisfying intimate relationships.

·       After more sessions: 2) Greater understand how his past is influencing his current reality including his relationships with his mother, brother and father and his difficulties with intimate relationships.

Therapist’s therapeutic goals

·       Create a sense of earned secure attachment in Daniel which will facilitate behavioural change particularly around relationships

General concepts

The therapeutic relationship, Bowlby (2008) argued, was similar to an attachment relationship:

…The therapist acts as an attachment figure by creating a secure base for the distressed client, providing the client, time, space and safety to explore themselves and their interpersonal environment. Through the therapist providing corrective emotional experiences, the individual’s internal working models of relationships are reshaped.” (Bucci et al, 2015).

Session 1 – Providing safety, security and acceptance to build trust

Session 1 is predominantly about allowing Daniel to feel safe, understood and validated (Homes, & Slade, 2018). The session will consist of rapport building and gathering background information. Setting boundaries around payment terms, lateness, and cancellation is a moment where Daniel may perceive as rejection or betrayal and react, however imperceptibly, but this is an important opportunity to build a sense of security by not reacting defensively or critically (Muller, 2010, p. 56). Validating Daniel’s self-sufficiency and communicating a desire to help but understanding that returning to therapy is Daniel’s choice allows him to use his existing defensive strategy of self-reliance to maintain a feeling of safety.

 

Session 2 – Demonstrating consistency and acceptance to build trust

It is unlikely in reality that one session would be enough time to create a safe haven and secure base for Daniel but for the purposes of this essay it can be assumed it has been enough. By having sessions in the same place at the same times each week we can show Daniel we are consistent and begin to allow him to feel that other people can be trustworthy.

Session 2 is when we could, if a secure base was established, begin the real work of challenging Daniel’s attachment defences and demonstrating through modelling secure attachment, that he is accepted and will not be rejected.

Work with affect can begin which will be difficult for Daniel who, like most avoidants, has shut themselves off from their right brain, affect world (Wallin, 2007, p. 79). This is difficult work as it is almost entirely foreign to the avoidant client to let themselves feel. But demonstrating tolerance, containing the clients emotion, helping them process it goes a long way to deepening the clients belief that others can be trusted when they feel vulnerable.

Session 3 – Exploring vulnerability to build trust

Wallin (2009) wrote that

…for psychotherapy to provide the secure base that makes such integration [of dissociated feelings] possible, the therapist has to matter to the patient – and allowing the therapist to matter is, of course, at odds with the deactivating strategy of the dismissing patient, which depends on diminishing the importance of others. Thus the central challenge is to enable the patient to allow the therapist to matter. (Wallin, 2009, p. 212)

A balance must be struck between empathic attunement and confrontation. Muller (2009, 2010) has written extensively about treatment of the avoidant. His argument is that treatment must run counter to the defensive strategy favoured by clients, “we need to activate the attachment system, turning their attention towards attachment related experiences and challenges defensive avoidance” (Muller, 2009, p. 70). It is interesting to note that this method is in line with research (Bruck, Winston, Aderholt, & Muran, 2006; Petrowski, Nowacki, Pokorny, & Buchheim, 2011) which shows that opposing client and therapist attachment styles are associated with better alliance and outcome.

With gentle challenges to Daniel’s deactivating strategies we allow Daniel to see that he is not rejected. He can be vulnerable and safe. This softens his defences not activates them (Daniel, 2014). By modelling secure behaviour and repairing ruptures Daniel can witness inter-subjectivity and connection and begin to really believe something that might be foreign to him. He is accepted for being himself. Then the therapist will really matter to the client.

Conclusion

Working therapeutically with the avoidant client is difficult. Defensiveness, the very issue they need to examine, gets in the way of examination. It’s a Catch-22 situation for the therapist: by examining the client’s defences, the therapist risks provoking the client’s defences and possibly early termination of therapy, but by not examining their defences, the therapy risks being ineffective.

After a lifetime of avoidance, a good therapist must walk a tightrope and help their client to avoid avoidance.

References

 

Bartholomew, K., & Horowitz., L.M. (1991). Attachment styles among young adults: a test of a four-category model. Journal of Personality and Social Psychology, 61(2), 226-244.

Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books

Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation. New York: Basic Books

Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss. New York: Basic Books

Bruck, E., Winston, A., Aderholt, S., & Muran, J. (2006). Predictive validity of patient and therapist attachment and introject styles.(Author abstract). American Journal of Psychotherapy, 60(4), 393–406. https://doi.org/10.1176/appi.psychotherapy.2006.60.4.393

 

Bucci, S., Seymour-Hyde, A., Harris, A., & Berry, K. (2016). Client and Therapist Attachment Styles and Working Alliance. Clinical Psychology & Psychotherapy, 23(2), 155–165. https://doi.org/10.1002/cpp.1944

 

Cundy, Linda. (2018). Attachment and the Defence Against Intimacy: Understanding and Working with Avoidant Attachment, Self-Hatred, and Shame. https://doi.org/10.4324/9780429447860

 

Daniel, S. (2014). Adult Attachment Patterns in a Treatment Context: Relationship and Narrative. London: Routledge.

 

 

Fuchshuber, J., Hiebler-Ragger, M., Kresse, A., Kapfhammer, H., & Unterrainer, H. (2019). The Influence of Attachment Styles and Personality Organization on Emotional Functioning After Childhood Trauma. Frontiers in Psychiatry, 10, 643. https://doi.org/10.3389/fpsyt.2019.00643

 

Greenberg, L. (2002). Termination of experiential psychotherapy. Journal of Psychotherapy Integration, 12, 358-363.

Hobson PR, Patrick M, Crandell L, García-Pérez R, Lee A. Personal relatedness and attachment in infants of mothers with borderline personality disorder. Development and Psychopathology. 2005;17:329–347.

 

Holmes, J., & Slade, A. (2018). Attachment in therapeutic practice. London.

 

Main, M. (1990). Cross-cultural studies of attachment organization. Recent studies, changing methodologies and the concept of conditioned strategies. Human Development, 33, 48-61.

 

Mikulincer, M., & Shaver, P., (2004). Security-based self-representations in adulthood: Contents and processes. In W.S. Rholes & J.A. Simpson (Eds.), Adult attachment: Theory, research and clinical implications (pp. 159-195). New York: Guilford Press.

 

Mikulincer, M., Shaver, P., & Berant, E. (2013). An Attachment Perspective on Therapeutic Processes and Outcomes. Journal of Personality, 81(6), 606–616. https://doi.org/10.1111/j.1467-6494.2012.00806.x

 

Moullin, S., Waldfogel, J., & Washbrook, E. (2018). Parent–child attachment as a mechanism of intergenerational (dis)advantage. Families, Relationships and Societies, 7(2), 265–284. https://doi.org/10.1332/204674317X15071998786492

 

Muller, R. T. (2010). Trauma and the avoidant client: Attachment-based strategies for healing. New York: W.W. Norton & Co.

 

Pec, O., Bob, P., & Raboch, J. (2014). Splitting in schizophrenia and borderline personality disorder. PloS one, 9(3), e91228. https://doi.org/10.1371/journal.pone.0091228

 

Petrowski, K., Nowacki, K., Pokorny, D., & Buchheim, A. (2011). Matching the patient to the therapist: the roles of the attachment status and the helping alliance. The Journal of Nervous and Mental Disease, 199(11), 839–844. https://doi.org/10.1097/NMD.0b013e3182349cce

 

Tatkin, S. (2009). I want you in the house, just not in my room…unless I ask you: The plight of the avoidantly attached partner in couple’s therapy. New Therapist Magazine, 62, 10-16.

 

Tyrrell, C., Dozier, M., Teague, G., & Fallot, R. (1999). Effective Treatment Relationships for Persons With Serious Psychiatric Disorders: The Importance of Attachment States of Mind. Journal of Consulting and Clinical Psychology, 67(5), 725–733. https://doi.org/10.1037/0022-006X.67.5.725

 

Van der Kolk, B.A.. (2014) The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma. New York: Penguin.

 

Verhage, M.L. et al (2016) Narrowing the transmission gap: A synthesis of three decades of research on intergenerational transmission of attachment, Psychological Bulletin, vol 142, no 4, pp 337–366.

Wallin, D. (2007). Attachment in psychotherapy. Guilford Press.