What’s the Attachment Theory and How Does it Shape the Therapist-Patient Relationship

attachment theroy. Woman with red hair and braided hair looking at bushes. She is displayed from behind.

When I decide to take a vacation from my clinical practice I appreciate that this departure from and then reunion with my clients is more meaningful than meets the eye. Upon separating from my practice, my clinical concern has typically focused on leaving my patients. However, our reunion is often when our therapy can be enhanced or destroyed or somewhere in between. How can vacations during the process of therapy mirror and bring to the surface memories and unconscious experiences for eating disorder patients originating from early attachment processes with their primary caregiver?

In preparing to leave on a vacation, I take into consideration how and when I begin to tell my patients that I will be leaving them. This conversation can help re-frame the vacation as an opportunity for growth and as yet another corrective emotional experience that helps to increase my client’s confidence and self-efficacy in managing other losses and separations. For instance, when I told Stella four weeks in advance that I would be leaving for 5 weeks last summer, we had the opportunity to talk about my absence over time. Stella began to explore in session how she might use our customary session time while I was gone. When we explored this idea more acutely, Stella realized that by thinking about deliberately filling our usual therapy hour with “something else to do” she would be able to potentially replace me with something else rather than experience missing me. The void that Stella thought she may have to experience scared her and she related this to her early childhood experiences of being repeatedly forgotten to be picked up at school by her mother.

The mere idea of considering that I could potentially forget her or as she stated, “what if you don’t return,” generated very sad and insecure feelings in Stella.

Stella most likely formed an insecure attachment with her mother, a defense to protect herself from being engulfed in a wave of abandonment for future losses. Stella’s adult attachment process mirrors this and by trying to replace me while I was away Stella  would be able to protect herself before she potentially felt forgotten by me. I have known Stella for almost 10 years. She began therapy to address her bulimia. Stella has not been symptomatic for close to 7 years and has remained in therapy to address interpersonal issues. Our discussion regarding my vacation gave rise to how Stella’s past colors how she perceives and experiences me. My vacation instigated both Stella and I to understand some of her unconscious motivations and reactions. We were also able to effectively use the unconscious material by giving therapy time to talk about the meaning of my leaving to Stella. This is important because even though talking may not ward off the acting out of unconscious urges it can be a bridge for insight and further capacity to regulate emotions that are historically too terrible to experience fully in one’s mind.

According to John Bowlby, every human being is born to attach to others and our primary attachment figure is our mothers. He identified different styles of attachment: secure, insecure and ambivalent and created the term “Inner Working Models” of attachment. Mary Ainsworth expanded upon Bowlby’s ideas and looked at mothers and their toddlers in what was called “The Strange Situation.” In this landmark study, Ainsworth was concerned with understanding the attachment processes a child has with its mother upon reunion after a brief separation. It was during the reunion phase of the experiment that Ainsworth discovered different behaviors displayed by children that suggested the child may be feeling safe, angry, frustrated, dismissive, preoccupied and anxious.  

If you are someone who leans more toward a dismissing attachment style your unconscious defenses are geared at reducing the importance of your relational experiences. Often a reliance on denial is heavily weighed upon in order to deal with internal conflicts and feelings. In therapy, a dismissive style may minimize the impact or importance of your therapist’s vacation and insist you have no problem with breaks in the treatment. Everything about this style indicates an attempt to defend against pain that arises in response to experiences of rejection and not necessarily an expression of your lack of interest in attachment. Stella, for example, had to adopt a dismissive attachment style in order to endure the pain of being forgotten and rejected as a child.  It was not until my vacation during our treatment that we were able to address more consciously our relationship and how to balance her internal fears and conflicts about being attached to me and to therapy.

In addition to using the “going on vacation discussion” as an opportunity to bring the unconscious conscious, the “reunion discussion” is an equally if not more rich discussion to bring out of awareness material to the conscious. When the unconscious remains unspoken and unacknowledged there is a greater risk for emotional dysregulation to repeat itself in the therapy relationship.

When there are vacations during therapy, this can be an opportunity to bring material about the therapy relationship, in particular, the attachment processes involved between therapist and patient, to the surface and potentially regulate the emotional states.

For instance, when I returned from my 5 week vacation and met with Stella for the first time she said proudly, “So, now I am going on vacation.” I thought this was a timely maneuver on her part to expunge some of her anger at me for leaving her. She needed to feel these feelings in addition to being able to take her own vacation from me. So, I responded, “How did you come to decide to go away?” she said, “I want to take my friends home to see where I grew up. I decided while you were away, two weeks ago and I booked my ticket.” Upon my return from abandoning her, Stella, like the dismissive children in Ainsworth’s study, rejected me and my return to her life. Stella and I explored the possible dynamics around her decision-making in relationship to my vacation and leaving her. Inviting her to use her words to describe her internal experience brought up new insights and an opportunity for me to support her in her independence while deepen our therapeutic relation. The process of Stella talking in therapy strived to accept or promote her emotions including previously evaded emotions in order to allow the her to tolerate and transform them into adaptive emotions. This psychological corrective emotional experience led to Stella being able to emotionally regulate more effectively.

After Stella’s vacation, we had additional opportunities to talk openly about our relationship, her therapy and the place it holds in her life today. By incorporating this vacation experience, it’s separation and reunion, into Stella’s regular therapy process has proven extremely beneficial and her growth seems even more profound. Because Stella was at a point in her therapy where we could talk candidly about her decision process and emotional regulation, we were able to grasp a much deeper process within her that impacts her on a day to day basis across the spectrum of her relationships. In part, her willingness to participate in this type of conversation also influenced me to examine the process of leaving on a vacation and returning from a vacation with each of my clients more carefully and sensitively.


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