Giovanni Liotti
The therapeutic alliance is the best predictor of outcome across a range of treatment modalities. Repairing the ruptures in the therapeutic alliance should, therefore, be a major concern for any psychotherapist, including cognitive-behavioural therapists (Chapters 9 and 10, this volume). The aim of this chapter is to clarify the role of attachment theory and research in helping therapists to understand the motivational underpinnings of alliance ruptures and to devise ways of coping with them in the therapeutic relationship.
Attachment theory (Bowlby, 1982) is part of a multi-motivational view of human relatedness based on evolutionary thinking. According to this view, human beings are biologically adapted for participating in at least four different types of interpersonal exchanges: careseeking–caregiving, dominant–subordinate, sexual and cooperative exchanges (Gilbert, 1989, 2000, 2004; Liotti, 1994, 2000; Liotti & Intreccialagli, 2003). The attachment system is conceived as a control system regulating careseeking behaviour. It is based on an inborn, evolved disposition to actively search for help or soothing from a member of the social group, perceived as stronger and/or wiser than the self (Bowlby, 1979, p. 129), whenever one is distressed or vulnerable to any type of danger. The expression of this disposition depends on memory structures, called internal working models (IWMs), that convey learned expectations of how other people will react to one’s requests for help and soothing (Bowlby, 1979, 1982, 1988).
The therapeutic alliance implies the prevailing activity, within the therapeutic relationship, of the cooperative motivational system in both partners of the clinical exchange. The cooperative system is based on the inborn tendency to share intentions, goals and action plans on equal grounds (Tomasello, 1999; Tomasello, Carpenter, Call, Behne & Moll, 2005). Ruptures of the therapeutic alliance become possible whenever the therapeutic relationship shifts from a mainly cooperative clinical dialogue to enduring patterns of careseeking–caregiving, dominant–subordinate (i.e., competitive) or sexual interactions between patients and therapists. Many ruptures in the therapeutic alliance, even when they involve competitive or sexual interactions, can be traced back to the operations of the patient’s attachment system. This assertion implies that the effort of repairing ruptures of the therapeutic alliance often provides the opportunity for corrective experiences in the therapeutic relationship, that may lead to healthy changes in the patient’s IWM of attachment.
In order to explore how dysfunctional mental operations linked to the attachment system may emerge within the therapeutic relationship and hamper the therapeutic process, this chapter deals first with the general reasons for the activation of the attachment system within the therapeutic relationship. A second section summarizes what is known about the main different types of IWM: activations of the attachment system within the therapeutic dialogue become counterproductive to the aim of the treatment only when they are governed by an insecure, and particularly by a disorganized, IWM. The other sections of this chapter deal with the different types of insecure IWM that may interfere negatively with the therapeutic alliance and the process of psychotherapy, and with some ways of coping with them and achieving their correction towards greater attachment security within the therapeutic relationship. It should be emphasized that successful attempts at repairing ruptures in the therapeutic alliance involve, first, achieving attachment security within the therapeutic relationship, and only afterwards regaining a cooperative attitude towards a shared goal. In other words, regaining a collaborative relationship after a rupture of the therapeutic alliance is usually achieved through empathic (i.e., non-judgemental and non-defensive) explorations of the patient’s motives and negative expectations that led to the crisis in the therapeutic relationship. The cooperative interactions that characterize the therapeutic alliance should convey a warm, empathic feeling tone, not a cold, task-focused one.
Cognitive and behavioural psychotherapists usually strive to shape the therapeutic relationship, from the very first session, according to the ideal of collaborative empiricism (Beck & Emery, 1985). This is performed usually through the active search of an explicit agreement on goals and rules of the therapeutic work (Chapter 10, this volume). Even with difficult patients, who may be unable to provide a credible personal goal for the treatment, cognitive therapists try to construct mutual agreement on shared goals at the beginning of the treatment through carefully devised contracting procedures (e.g., Linehan, 1993; see also Chapter 11, this volume).
If the joint formulation of a shared goal for the treatment has been successful, the motivational system mediating cooperative behaviour is likely to become active both in the therapist and in the patient at the beginning of the treatment. However, other role-forming elements that extend beyond collaborative activity arise from the fact that, from the beginning of psychotherapy, patients are gradually disclosing their troubles, distress, feelings of shame and fear, with the hope that the therapist is benevolent, understanding, accepting, emotionally available and capable of providing efficient help (i.e., the therapist is hopefully perceived as “stronger and/or wiser” than themselves: Bowlby, 1979, p. 129). Disclosing one‘s suffering to an available person who is perceived as stronger and wiser than the self, normally and adaptively activates the attachment system, “from the cradle to the grave” (Bowlby, 1979, p. 129). Therefore, in the course of psychotherapy, the cooperative system will almost inevitably give way to the attachment system (Liotti, 1991, 2000). The activation of the care-seeking aspects of the attachment system within the therapeutic relationship is suggested by a variety of signs. For instance:
The shift from a cooperative reciprocal attitude (in which patient and therapist interact on equal grounds, both aiming at the shared therapeutic goal) to an attachment–caregiving type of interaction (in which the patient asks for soothing responses and the therapist signals safety via non-verbal communication from facial expressions to warm tone of voice) may not be a durable or serious challenge to the therapeutic alliance. Indeed, the ability to move into these “attachment-like” forms of relating can be helpful in that they provide information that the therapist creates a safe base and is able to be a source of validation and mirroring. In fact, if the patient does not experience a therapist as wiser/stronger and able to contain and help make sense of the material that emerges in the interaction, the patient may feel unsupportive and fearful – re-enacting traumas from the past (Liotti, 2000).
If the temporary attachment–caregiving interaction between patient and therapist is secure (i.e., if the therapist judiciously provides context-appropriate soothing, mirroring and validation responses without becoming overprotective or violating the professional boundaries of psychotherapy, and the patient accepts the therapist’s response by calming down quickly), then the therapeutic process usually resumes the cooperative atmosphere centred on the joint awareness of the therapeutic goal. If, however, the attachment–caregiving interaction between patient and therapist is insecure – i.e., the therapist becomes alarmed at the care-seeking behaviour of the patient, ignores it (appears not to have noted or “heard”), dismisses it, or tries to “force” the patient back to a “collaboration” – then the therapeutic relationship is likely to become problematic and the therapeutic process hampered.
The main cause for attachment–caregiving interactions between patient and therapist becoming insecure (provided therapists have learnt to recognize in themselves and to control a possible dysfunctional caregiving attitude) is the activation in the patient of an insecure IWM constructed on the basis of previous unhealthy attachment relationships. It should be emphasized that if the therapist’s reply to the manifestation of the patient’s insecure IWM within the attachment relationship confirms the patient’s negative expectations about attachment-caregiving interactions, then a therapeutic stalemate or even a worsening of the patient’s psychopathological symptoms is likely to occur. The rationale for this assertion can be inferred by the notion that the development of many emotional disorders stems from insecure attachments, so that the basic cognitive–emotional structure of symptoms is intertwined with the IWM (Bowlby, 1979; Dozier, Stovall & Albus, 1999; Greenberg, 1999; Guidano & Liotti, 1983).
This chapter will discuss how psychotherapists deal with a patient’s insecure IWM in the therapeutic relationship, so that they can avoid confirming it and possibly foster corrective relational experiences while trying to regain a cooperative working alliance. In order to introduce this discussion, a brief reminder of the main types of IWM is mandatory.
The IWM is a cognitive–emotive structure based on memories of previous careseeking–caregiving relationships, conveying expectations about the meaning, value and outcome of ongoing or future interactions involving the attachment motivational system. Secure IWMs convey positive expectations that others will generally be helpful and sympathetic, while insecure ones convey expectations that one’s attachment needs will be met with rejecting, intrusive, fearful or violently aggressive responses.
At the beginning of life, the IWM is a structure of implicit memory (Amini et al., 1996), constructed on the basis of actual interactions with the primary caregiver. Once established, the IWM guides both attachment behaviour and the appraisal of attachment emotions in self and others. Gilbert (1989, 2005) suggested that attachment experiences affect both threat and safeness processing systems, such that (for example) neglectful or abusive early attachments can sensitize threat systems that will impact on a person’s whole orientation to self, others and the world (i.e., not just attachment relationships; cf. Cortina, 2003, and Grossmann & Grossmann, 1991). In essence, attachment relationships help set the “working tone and threshold activation level” of threat and safeness systems. If the attachment figure has been accessible to the child in real-life situations, the corresponding IWM of the developing child conveys an inner sense of legitimacy of the attachment emotions and of potential accessibility of help and comfort even when the attachment figure is not actually present during distressing experiences. This is the IWM of secure attachments. In contrast, the IWMs of insecure/ organized attachments convey negative expectations: that the attachment figure will be bored by and will not be available to requests of help and comfort (avoidant attachment), or that he/she will respond ambivalently and intrusively to such requests (resistant attachment). The IWM of insecure/ disorganized attachment differs from that of avoidant and resistant attachments because it not only prefigures negative consequences of asking for help and comfort, it also brings on a dissociated (non-integrated) multiplicity of dramatic and contradictory expectations. Disorganized attachment in infancy is the outcome of unresolved traumas and hostile–helpless, frightened and frightening attitudes in the caregivers. It is often related to further traumas suffered by the child within the attachment relationship, leading to borderline and dissociative disorders (Liotti, 1992, 1999, 2004a, 2004b; Lyons-Ruth, 2003; Main & Morgan, 1996).
In later phases of personality development, part of the formerly implicit IWM may become explicit and enter both into the consciously held meanings attributed to attachment needs and into the narratives of autobiographic memory. Although open to modification because of later attachment experiences, the early IWMs show remarkable stability over time (presumably because the relational style between child and parents also remains stable: Bowlby, 1982, 1988). In adult life, the individual state of mind concerning attachment can be assessed with the Adult Attachment Interview (AAI: Hesse, 1999). States of mind characterized by appraisals of basic attachment emotions as legitimate and normal are linked either to early secure attachments or to security in attachment–caregiving interactions that have been earned through later corrective experiences. Early avoidant IWMs are related to adult states of mind that dismiss the value of attachment-related emotions and interpersonal exchanges. States of mind preoccupied as to the meaning and value of attachment experiences are linked to early resistant IWMs. Early disorganized attachments are related to adult states of mind that are characterized by the tendency to attribute multiple, non-integrated, dramatic meanings to attachment experiences (these states of mind may appear in the AAI as unresolved memories of attachment-related traumas and losses, and as representations of self and others portraying high degrees of both hostility and helplessness that are reciprocally dissociated (Hesse, 1999; Lyons-Ruth, Melnick, Atwood & Yellin, 2003) (see Table 7.1).
Patients with an avoidant IWM typically have difficulties in revealing painful emotional information. They have learnt to be fearful of inner cues and affects that suggest unmet needs, because in the past expressing needs often required approach behaviour to a parent, and need-seeking that was punished or shamed. They are often very concise in reporting to the therapist, usually in a matter-of-fact tone of voice, interpersonal experiences (including ongoing ones with the therapist) in which they are likely to have felt the wish to be soothed and helped. They may also dismiss this wish as insignificant (Liotti, 1991). Attachment theory and research suggest that they do so because they expect the therapist (often at an implicit, nonconscious level of cognitive processing) to shame them for the need, and to be annoyed or bored by their suffering should they dwell on it and/or express it non-verbally.
This hypothesis prompts therapists to show immediate, explicitly empathic attitudes (and validating comments: Leahy, 2005) to every, however minor, description or expression of painful emotions. “How did you feel?” is a question that should be frequently asked by therapists in these cases, whenever patients report, in their typical dismissing way, interpersonal episodes likely to imply attachment dynamics. Any comment on the patient’s expressed emotion that could be felt as critical and shaming should be carefully avoided. On the contrary, therapists should take pains over showing to the patients that expressing attachment emotions (i.e., fear, pain, discomfort, loneliness, sadness for losses, wish for comfort, joy at reunions after separations, etc.) is welcome, normal to being a human being, not shameful and not annoying the therapist in the least. In other words, therapists should help patients re-code these feelings or felt needs from being threatening to being safe to share and explore.
It should be remarked that such a therapist’s attitude in the therapeutic relationship may cause a temporary imbalance in the patient’s attachment representations. In the transition from avoidant to secure attachment, ambivalent states of mind reminiscent of resistant attachment (see below) are common. The shift from an avoidant IWM to a less desperate expectation about the consequences of expressing wishes for help and comfort implies ambivalence and doubts during the unfolding of the therapeutic process: will a new person to whom a request for soothing is addressed respond as the therapist does, or will he/she respond with rejecting annoyed attitudes, as the former attachment figures did? Will the therapist consistently respond as he/she had until now, or will he/she finally get irritated by the patient’s expressed emotions (that the patient may still perceive as lack of autonomy)? Before security develops, the therapeutic relationship should accommodate this transition by acknowledging both its meaning and the need for repeated experiences of validation of attachment emotions.
Patients coming from histories of avoidant attachment are particularly prone to provide unrealistically positive “semantic” descriptions of their attachment figures while at the same time they are usually unable to report autobiographical memories supporting these descriptions (Hesse, 1999). When they become able to report episodes of actual interactions with their primary caregivers, these reports typically contradict the idealized picture of past attachment relationships the patients may have provided on the semantic level. This de-linking between autobiographical and semantic memories may be usefully explored in the therapeutic relationship. When the patient’s attitudes toward the therapist become ambivalent, oscillating between dismissing of attachment emotions and anxious, clinging requests for comfort, time is ripe for an enquiry into the manner of careseeking- caregiving interactions in the patient’s childhood. Idealizing semantic memories of these interactions (e.g., “My parents were exceptionally good parents”) should be matched by the therapist’s detailed, albeit tactful, enquiry on childhood episodes that could illustrate their alleged happiness (e.g., “How did your parents respond to your childhood illnesses? Could you provide a concrete example? How did they soothe you when you were emotionally distressed? You said they were perfect at that. Could you narrate a precise episode that could help me understand what you mean by ‘perfect’?”). The aim of such an enquiry is to assist patients in acknowledging that they have had reasons for expecting rejecting responses to their requests for help or comfort: these expectations make it understandable both that they at times avoid expressing painful emotions and wishes to be soothed, and that in other moments they express them in a very anxious way.
Patients coming from histories of resistant (ambivalent) attachment present almost opposite types of problem in the therapeutic relationship. They usually express freely and intensely their attachment-related emotions to their therapist, easily develop clinging dependency on the therapist, and dwell on their experience of emotional pain at great length. At the same time, they seem unable to calm down in the face of any attempt the therapist could make at sympathizing with their distressing experiences and worries, or at reassuring them about their fears. Patients with hypochondriac and other anxious worries may be typical examples (Liotti, 1991). Attachment theory and research suggest that people with resistant attachments expect that the positive responses to their requests to be soothed will soon prove to be inconsistent and inept, or will shift towards intrusive attitudes. This hypothesis may prompt therapists to show that they are willing and able to help the patient in a concrete way, rather than merely listening sympathetically to their lamentations or trying to reassure them verbally. A good example of this is therapists who, after having declared that they are willing to reassure their patients from their hypochondriac or obsessive–compulsive fears as long as they ask for, enquire as to whether or not patients believe that such reassurances will prevent them relapsing quite soon in their worries. Since patients usually acknowledge that this is not likely to happen, therapists can thereupon remark that there are ways of helping the patient to achieve inner serenity that are different from mere reassurance. The proposal of a cognitive or behavioural technique aimed at increasing the patient’s coping abilities or the patient’s mastery over common interpersonal problems is likely to substantiate this assertion. For instance, once they have obtained the patients’ agreement on giving up the request for verbal reassurance, therapists may guide patients in acknowledging that a hypertrophic sense of responsibility lies at the ground of their hypochondriac or obsessive–compulsive worries (Salkovskis, 1985). If patients acknowledge that an abnormal sense of responsibility rather than a real impending danger is causing their worries, the therapeutic technique will have provided effective soothing of the patients’ fear, while therapists avoided confirming the patients’ expectation (linked to their resistant IWM) that the attachment figure’s reassurances are inefficient.
Patients with histories of resistant attachment are perhaps those that may benefit from corrective relational experiences, leading to increased attachment security, in the therapeutic relationship with therapists that skilfully use standard cognitive-behavioural techniques. These patients will experience concrete, consistent help rather than a mere empathic listening that would fall short of what is required in order to contain their painful emotions and to correct their expectation of inept, inconsistent responses to their need to be soothed.
The above description of common problems in the therapeutic relationship illustrates the contribution of attachment theory in understanding their meaning and the underlying cognitive–interpersonal processes. It is, however, the knowledge of attachment disorganization that may contribute to an understanding of more dramatic difficulties and dilemmas in the therapeutic relationship, such as those that should be expected when treating patients in the borderline–dissociative spectrum of complex syndromes related to severe chronic childhood traumas (Liotti, 2004a, 2004b).
When therapists face interpersonal situations where patients assume a controlling–punitive or a seductive attitude, threaten self-harm or premature interruption of treatment, and in any other ways induce in the therapist shifting feelings of solicitude, threat and impotence, the possibility that a disorganized IWM is guiding the patients’ appraisal of the therapeutic relationship should be considered (Liotti, 2004a, 2004b).
It has been argued that the IWM of disorganized attachment conveys multiple, reciprocally dissociated and dramatic representations of both self and the attachment figure that can be rendered by the prototypic representations of the omnipotent rescuer, the impotent victim and the malignant abuser/persecutor (Liotti, 1999, 2000, 2004a, 2004b). When the disorganized IWM becomes active within the therapeutic relationship, these three representations may reflect themselves in powerful and multiple, sometimes quickly shifting, transferential–countertransferential reactions. In these multiple transferences–countertransferences, the three roles of persecutor, abuser and victim can appear in both partners and in any particular order or sequence. A common sequence is for the therapist to start out in the role of rescuer (a role to which therapists are inclined), while the patient begins in the role of victim, for example by reporting very traumatic experiences suffered during childhood at the hand of a cruel attachment figure. Inadvertently, therapist may solicitously strive to repair the damage by extending hours, not collecting the fee, taking repeated late-night calls and even hugging the patient. Demands by the patient may escalate until the therapist begins to feel tormented, as though a victim of the patient, who is now viewed as an abuser. The therapist, however, may also feel the risk of becoming the cruel persecutor of the patient should he/she relinquish the care of a deeply suffering victim of childhood attachment-related abuse, rejection and neglect.
The situation is complicated by the fact that, in order to preserve early attachment relationships from the annihilating experience of disorganization, children who have been disorganized in their infant attachments usually develop controlling strategies towards their caregivers (Hesse, Main, Abrams & Rifkin, 2003). The controlling strategies may involve, in situations where the attachment system should motivate the child’s behaviour, the activation of the competitive-ranking system (controlling–punitive strategies), the caregiving system (controlling–caregiving strategies that imply inversion of the attachment relationship with parents) and even the sexual system (leading to sexualized interactions with a parent). The early construction of controlling strategies to cope with attachment disorganization explains how patients that are motivated to ask for psychotherapeutic help (attachment motivational system) may quickly activate the competitive or the sexual motivational systems in the therapeutic relationship (or even the caregiving system, leading to rather paradoxical interactions in which patients are preoccupied with the well-being of their therapists, a concealed motivation sometimes betrayed by patients’ gifts to the therapist).
Many cases of sexual relations between therapist and patient have followed this model, where the therapist, under the guise of trying to love the patient back to health, surrenders to the patient’s sexual seduction and becomes an abuser (Gabbard & Lester, 1995). In such cases therapists are often oblivious to the possibility that they are repeating the same kind of incestuous relationship that might have occurred in the patient’s childhood. This is a disaster, for the therapist has failed to contain the confused and confusing desires for safeness that lie behind these interactions. The therapist can become the abusive other to the controlling/disorganized patient in other, less dramatic ways. For example, when facing a patient’s controlling–punitive strategy, the therapist may start making sarcastic or sadistic comments, may stop paying attention, may be late at sessions, or may force the patient to relive horrendous childhood experiences (thereby re-traumatizing him/her).
Even when the therapeutic relationship is safeguarded from such deleterious occurrences by a proper therapist’s attitude, the activation of a patient’s disorganized IWM is a serious challenge to the psychotherapy process. For instance, the therapist may be disoriented by alternating manifestation of clinging dependency (when the therapist is perceived as an omnipotent rescuer) and of “phobia of attachment” (when the patient construes the therapist’s behaviour as that of a potential abuser: Steele, Van der Hart & Nijenhuis, 2001). Or therapists may feel paralysed by the relational dilemma they perceive in their disorganized patients: traumatic memories of abuses inflicted by attachment figures must be dissociated in order to safeguard the attachment relationship, while at the same time the need for attachment must be disavowed in order to protect the self from the betrayal of attachment needs implied by the abuse (Blizard, 2001; Freyd, 1997). In short, attachment disorganization creates a specific approach-avoidance dilemma, which must be solved within the therapeutic relationship: searching for meaning in the clinical dialogue potentially increases the patients’ sense of security, but at the same time the very words used in such a quest for meaning may arouse terrifying memories of attachment trauma (Holmes, 2004).
It is unlikely, in the treatment of difficult patients, that therapists successfully deal with the disorganized IWM through the identification of its cognitive components and active reflection upon them. The reason is that the implicit structures of severely disorganized attachment, when they emerge in the therapeutic relationship, seriously hinder the patient’s metacognitive capacity of reflecting on ongoing interpersonal experiences (see, e.g., Fonagy, Target, Gergely, Allen & Bateman, 2003; Liotti, 2000, 2004a). It is therefore necessary to cope with the disorganized IWM at the implicit, non-verbal, emotional level of clinical exchanges.
Gold (2000) and Liotti (1994, 2000, 2004a) propose to carefully organize the overall therapeutic strategy along the lines of a collaborative relationship implying the careful building and rebuilding of the therapeutic alliance, so that both patient and therapist can perceive themselves and the other as striving on equal grounds towards a shared goal. If such a cooperative interpersonal perception is achieved, then attachment needs (and therefore disorganization) are kept at bay during the clinical dialogues, before one attempts to foster experiences of secure attachment within the therapeutic relationship (see also Gold et al., 2001). Dialectic Behaviour Therapy (DBT: Linehan, 1993), although it is not grounded in attachment theory, provides very useful hints at how this goal – implicit correction of the disorganized IWM in the direction of attachment security – can be pursued in the context of exchanges between therapist and patient that are explicitly based on a cooperative therapeutic alliance.
While DBT is based on the careful contracting of the therapeutic alliance since the beginning of the treatment, by explicit statement of the symmetrical responsibilities that therapist and patient agree to take during the whole therapeutic process (see Chapter 11, this volume), it also suggests that the therapist’s attention focuses primarily on a series of targets that are easily related to the patient’s attachment needs. These targets are organized according to a hierarchy of priorities. At the top of this hierarchy is the patient’s safety. If the patient’s life is in danger (for example, because of explicit or subtle threats of committing suicide), then the therapist should immediately suspend, whenever this may happen throughout the treatment, any other therapeutic manoeuvre in order to concentrate on the patient’s safety. The second level of the hierarchy of priorities for the therapist’s attention concerns the safeguard of the therapeutic relationship. Whenever during the therapeutic process the continuity or the significance of the therapeutic encounter is endangered (not only by threats of premature interruptions of the treatment, but also by the patient’s being late to the sessions or coming to the session in an altered state of consciousness because of abusing alcohol or drugs before the session), and provided that no threat to the patent’s life is impending (in this case the patient’s safety is the priority), the therapist will stop paying attention to anything else in the therapeutic dialogue, however interesting other topics for conversation may appear to be to the patient. The third priority in the hierarchy of therapeutic targets is any behaviour that may hinder the quality of the patient’s life (i.e., any habit that may yield untoward results in the patient’s search for well-being). The fourth priority is any behaviour that may foster the quality of the patient’s life. The fifth is behaviour indicative of the effects of traumatic memories on the patient’s ongoing mental process (this usually becomes the focus of the therapist’s attention only in the second year of treatment, and when no behaviour of the preceding levels is momentarily present). The sixth is the patient’s ability to take care of themselves.
One can imagine how the patient may process, at an implicit level, the interpersonal information conveyed by the therapist’s continuing shifts of attention according to such a hierarchy of priorities. The shifts of the therapist’s attention implicitly mean:
These, besides constituting the basis for an experience of compassionate relating within the therapeutic relationship (Gilbert & Irons, 2005), are exactly the attitudes of an attachment figure that can foster attachment security. These therapist’s attitudes during the therapeutic process may gradually correct the patient’s past IWM, constructed on the basis of memories of interactions in which attachment figures may have directly or indirectly suggested to the patient, through violent deeds or bitter words, that they would prefer that the patient die rather than live, that they would like not having them around because they are an unbearable burden, that they do not care if they harm themselves or develop habits that will yield unhappiness and failure, that they do not even notice if they are shaming their children, and that they may not tolerate their children’s autonomy. Such a corrective relational experience does not require verbal exchanges dealing with the attitudes of the patient’s primary caregivers or with the patient’s state of mind concerning attachment, nor verbal comments or explicit techniques aimed at explaining how to develop secure attachments in the future. All this corrective relational experience may take place at the implicit level of cognitive processing where the shifts of another person’s attention, indicative of his/her prevailing interests, can first be registered and elaborated.
At the explicit level of cognitive processing, patients involved in DBT may notice and memorize also other types of relational information that correct their IWM in the direction of earned attachment security: while DBT therapists are busy teaching social and self-regulatory skills, they consistently show a positive, validating interest in the patient’s emotional experiences, both painful and happier ones. Validation of painful emotional experience by the therapist (for example, by explicitly acknowledging that the patient’s suffering involves a legitimate request for soothing) is another main road towards constructing attachment security (Leahy, 2005). Another ingredient of DBT explicitly aimed at fostering attachment security and therefore correcting the disorganized IWM is training in the art of properly asking for help, pursued by requiring phone calls to the therapist whenever the patient is in such serious trouble as to risk self-harming behaviours (Linehan, 1993).
The simultaneous engagement in the treatment of two therapists operating in different, parallel settings is perhaps the main aspect of DBT that facilitates coping successfully with the otherwise almost unbearable effects of severe attachment disorganization within the clinical dialogue. Although in DBT the two therapists operate in individual and group sessions (Chapter 11, this volume; Linehan, 1993), the lines of reasoning that explain the advantages of parallel interventions in the treatment of patients with severely disorganized attachments can be generalized to other types of two-therapist models (for example, individual and family interventions, or individual psychotherapy and psychologically informed prescription of drug treatments, conducted by different clinicians: Liotti, 2000, 2004a, 2004b).
If the patients’ relational dilemmas and the worsening of their most disturbing experiences of fragmentation are contingent upon the activation of the attachment system and of the corresponding disorganized IWM, then one could expect that such an activation will be more difficult to handle when the patient becomes attached to only one therapist. A good example is provided by what may happen when patients disorganized in their early attachments face the idea of a momentary separation from their therapists, for instance when the therapist’s summer holidays are approaching.
In the prospect of separation from their one therapist, often the only reliable source of soothing and support patients can count on, a strong and durable activation of the patient’s attachment system is to be expected. If the expected separation from the therapist activates an IWM of disorganized attachment, then the patient’s state of mind will be invaded by catastrophic expectations concerning the future of the therapeutic relationship. The patient’s consciousness will be obsessed by multiple, dramatic representations of self and the therapist that shift without integration between hostility, helplessness, desperate longing for help, guilt, fear and affect phobia. The patient will also lack the capacity of coping with these representations and affects through adequate metacognitive monitoring, self-reflection and critical reflection on the therapist’s possible states of mind, because the exercise of all these mentalizing capacities is hindered by the activation of disorganized attachment.
If, however, the patient is attached to two different therapists, then the prospect of a momentary separation from one of them is less likely to bring on a strong and durable activation of the patient’s attachment system. Another source of help and comfort will remain available. When one of the two therapists in a parallel treatment will leave, say, to participate in a conference, the presence of the second will make it less likely that the patient experiences exacerbation of symptoms, the appearance in consciousness of dramatic, multiple and non-integrated representations of self and the therapist, and a simultaneous decay in the exercise of self-reflective, mentalizing capacity. The risk of premature interruption of the treatment – not a rare occurrence in borderline and dissociative patients before and after momentary separations from the therapists – will be correspondingly reduced.
During the psychotherapy with borderline and dissociative patients, multiple transferences, i.e., quick oscillation of attitudes and states of mind towards self and the therapist, are common also in moments in which no separation is expected, but other types of experiences, such as intense mental pain, activate the patient’s attachment system. In a short span of time, even within a single session, these patients may dramatically ask for help, look distant and indifferent, state their wish to quit therapy because of the fear of being damaged, express the fear of being dangerous to beloved persons, and make the therapist feel important and loved but also threatened or oppressed (Fonagy, 1999; Liotti, 1995). This quick and dramatic change of attitudes, difficult to handle through transference interpretations also because of the patient’s metacognitive deficit, may become overwhelming for both the patient and the therapist.
With the benefit of a second therapy, the patient is often able to experience a full range of contradictory feelings of anger and longing for understanding, without being overwhelmed by the fear of completely destroying the relationship with the first psychotherapist. In the parallel model, these patients are offered a second attachment relationship that attenuates the terror of the “all or nothing” consequences so characteristic of these situations. Since the attachment relationship with the secondary therapist is usually less intense than that with the first therapist, the relational- emotional dilemmas are also less intense within the second therapeutic relationship, and the exercise of mentalizing capacities less hindered by the disorganized IWM. The second therapist, thus, may provide an opportunity to examine each component of the conflict with the first therapist, including fears of abandonment or retaliation. From such a secure base of empathic observation, patients can begin to tease out their own transferential material from the intersubjective context within which they are experiencing it. The second therapist can validate, support, and mirror all the contradictory aspects of the patient’s multifaceted subjective experience with the first therapist. The patient can then return to the first therapist, with whom he or she felt in conflict, less terrorized by his/her own feelings. By feeling securely anchored with the second therapist, the patient is now ready to address these previously fragmenting issues, and repair of the disrupted therapeutic alliance can now proceed.
From the point of view of the therapist’s countertransferential responses, the assistance of a second therapist may also be instrumental in preventing overwhelming feelings of confusion, helplessness, hostility or fear when facing the patient’s multiple, non-integrated and dramatic transferences. Parallel therapy is analogous to a typical family where two parents are available to meet the range of needs and feelings of a difficult child. Let us visualize the child with tears in his/her eyes and rage in his/her voice, contorting on the floor in a desperate attempt to be understood, and at the same time frightened by the parents’ possible rejecting or retaliating responses. In such situations, it is relieving if one parent can ask for the help of the other (“Please do something! I can’t take this anymore!”). At times, we see our borderline and dissociative patients in a similar developmental state, and we find ourselves as therapists in a state akin to that of the helpless–angry parent in the example. At such times, parallel psychotherapies not only offer the patient the prospect of a second and maybe more promising source of soothing; they also offer the first therapist the second one to turn to for help and support. If the first therapist, being aware of the helping availability of the second one, can contain his/her disappointment, frustration and helplessness, then the situation can be worked through. In the perspective of attachment disorganization, such a structure of the parallel psychotherapies reduces the likelihood that the therapeutic relationship becomes, for the patient, the scenario for the repetition of the original attachment trauma: meeting a confused, helpless, frightened and therefore frightening attachment figure just when the need for a soothing response is most intense. Parallel psychotherapy, thus, helps prevent the risk of re-traumatizing the patient through the repetition of the basic experience of disorganized attachment: increasing fear within the relationship that is expected to reduce fear.
Other ingredients of parallel therapies are also instrumental in correcting the basic deficits of disorders based on early attachment disorganization. Patients who, due to their insecure, chaotic and traumatic interpersonal environments, have rarely witnessed cooperation on equal grounds between their parents, can now learn that this is indeed a possibility in human interactions. By noticing, even if only at an implicit level, that the two therapists share a common attitude towards their problems and thus cooperate in their treatment, they can learn that human communication is not confined to care-seeking and care-giving, to competition for dominance, to punitive attitudes, and to sexual seduction. If a patient witnesses the possibility of cooperating on equal grounds by noticing how his or her two therapists exchange information and opinions concerning the treatment, he or she may also appreciate the benefits of a cooperative therapeutic alliance with each of his or her therapists, instead of shifting to aggressive, dependent or seductive attitudes within the therapeutic relationship.
Central to an attachment-based approach to the treatment of borderline patients is the recognition that two parallel therapies, rather than encouraging splitting, serve to acknowledge and contain painful and overwhelming feelings of fragmentation. Patients learn to observe their own internal experience as well as to observe themselves and the other in relationship, because the second therapy offers a secure base for exploring safely the conflicts that almost inevitably arise in the primary therapeutic relationship. However, if the patient witnesses rivalry and competition among his or her therapists, or their incapacity of dealing with diverging ideas without losing a cooperative and respectful reciprocal attitude, then the risk that a two- professional model instigates splitting in the patient’s mental processes becomes high indeed.
In summary: attachment theory suggests reflection on parallel treatments as the source either of re-traumatization within the therapeutic relationships, or of corrective relational experiences. The relationship between the two therapists makes the difference, according to whether it is akin or radically diverging from the style of family communications that most often underlies the development of borderline and dissociative disorders in the children: a frightened/frightening attachment figure engaged in conflicting or neglecting (rather than supportive and cooperative) interactions with the other parent.
Ainsworth, M.D.S., Blehar, M., Waters, E. & Wall, S. (1978). Patterns of attachment: A psychological study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum Associates.
Amini, F., Lewis, T., Lannon, R., Louie, A., Baumbacher, G., McGuinnes, T. & Zirker, E. (1996). Affect, attachment, memory: Contributions toward psychobiologic integration. Psychiatry, 59, 213–239.
Beck, A.T. & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.
Blizard, R.A. (2001). Masochistic and sadistic ego states: Dissociative solutions to the dilemma of attachment to an abusive caregiver. Journal of Trauma & Dissociation, 2, 37–58.
Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock Publications.
Bowlby, J. (1982). Attachment and loss. Vol. 1: Attachment (2nd edition). London: Hogarth Press.
Bowlby, J. (1988). A secure base. London: Routledge.
Cortina, M. (2003). Defensive processes, emotions and internal working models: a perspective from attachment theory and contemporary models of the mind. In M.
Cortina & M. Marrone (2003). Attachment theory and the psychoanalytic process (pp. 307–335). London: Whurr.
Dozier, M., Stovall, K.C. & Albus, K.E. (1999). Attachment and psychopathology in adulthood. In J. Cassidy & P.R. Shaver (eds), Handbook of attachment (pp. 497–519). New York: Guilford.
Fonogy, P. (1999). The transgenerational transmission of holocaust trauma: Lessons learned from the analysis of an adolescent with obsessive-compulsive disorder. Attachment and Human Development, 1, 92–114.
Fonagy, P., Target, M., Gergely, G., Allen, J.G. & Bateman, A.W. (2003). The developmental roots of borderline personality disorder in early attachment relationships: A theory and some evidence. Psychoanalytic Inquiry, 23: 412–459.
Freyd, J.J. (1997). Betrayal trauma: The logic of forgetting child abuse. Cambridge, MA: Harvard University Press.
Gabbard, G.O. & Lester, E.P. (1995). Boundaries and boundary violations in psychoanalysis. New York: Basic Books.
Gilbert, P. (1989). Human nature and suffering. London: Lawrence Erlbaum Associates.
Gilbert, P. (2000). Social mentalities: Internal “social” conflict and the role of inner warmth and compassion in cognitive therapy. In P. Gilbert & K. Bailey (eds), Genes on the couch: Essays in evolutionary psychotherapy (pp. 118–150). Hove, UK: Psychology Press.
Gilbert, P. (2004). Evolutionary approaches to psychopathology and cognitive therapy. In P. Gilbert (ed.), Evolutionary theory and cognitive therapy (pp. 3–44). New York: Springer.
Gilbert, P. (2005). Compassion and cruelty: A biopsychosocial approach. In P. Gilbert (ed.), Compassion: Conceptualisations, research and use in psychotherapy (pp. 9–75). Hove, UK: Brunner-Routledge.
Gilbert, P. & Irons, C. (2005). Focused therapies and compassionate mind training for shame and self-attacking. In P. Gilbert (ed.), Compassion: Conceptualisations, research and use in psychotherapy (pp. 263–325). Hove, UK: Brunner-Routledge.
Gold, S.N. (2000). Not trauma alone: Therapy for child abuse survivors in family and social context. Philadelphia: Brunner-Routledge.
Gold, S.N., Elhai, J.D., Rea, B.D., Weiss, D., Masino, T., Morris, S.L. & McInich, J. (2001). Contextual treatment of dissociative identity disorder: Three case studies. Journal of Trauma & Dissociation, 2, 5–35.
Greenberg, M.T. (1999). Attachment and psychopathology in childhood. In J. Cassidy & P.R. Shaver (eds), Handbook of attachment (pp. 469–496). New York: Guilford.
Grossmann, K.E. & Grossmann, K. (1991). Attachment quality as an organizer of emotional and behavioural responses in a longitudinal perspective. In C.M. Parkes, J. Stevenson-Hinde & P. Marris (eds), Attachment across the life cycle (pp. 93–114). London: Routledge.
Guidano, V.F. & Liotti, G. (1983). Cognitive processes and emotional disorders. New York: Guilford Press.
Hesse, E. (1999). The Adult Attachment Interview: Historical and current perspectives. In J. Cassidy & P.R. Shaver (eds), Handbook of attachment (pp. 395–433). New York: Guilford.
Hesse, E., Main, M., Abrams, K.Y. & Rifkin, A. (2003). Unresolved states regarding loss or abuse can have “second-generation” effects: Disorganized, roleinversion and frightening ideation in the offspring of traumatized nonmaltreating parents. In D.J. Siegel & M.F. Solomon (eds), Healing trauma: Attachment, mind, body and brain (pp. 57–106). New York: Norton.
Holmes, J. (2004). Disorganized attachment and borderline personality disorder: A clinical perspective. Attachment & Human Development, 6, 181–190.
Leahy, R.L. (2005). A social-cognitive model of validation. In P. Gilbert (ed.), Compassion: Conceptualisations, research and use in psychotherapy (pp. 195-217). Hove, UK: Brunner-Routledge.
Linehan, M.M. (1993). Cognitive-behavioral treatment for borderline personality disorder. New York: Guilford Press.
Liotti, G. (1991). Patterns of attachment and the assessment of interpersonal schemata: Understanding and changing difficult patient-therapist relationships in cognitive psychotherapy. Journal of Cognitive Psychotherapy, 5, 105–114.
Liotti, G. (1992). Disorganized/disoriented attachment in the etiology of the dissociative disorders. Dissociation, 5, 196–204.
Liotti, G. (1994). La dimensione interpersonale della coscienza [The interpersonal dimension of consciousness]. Rome: NIS.
Liotti, G. (1995). Disorganized/disoriented attachment in the psychotherapy of the dissociative disorders. In S. Goldberg, R. Muir & J. Kerr (eds), Attachment theory: Social, developmental and clinical perspectives (pp. 343-363). Hillsdale, NJ: Analytic Press.
Liotti, G. (1999). Disorganized attachment as a model for the understanding of dissociative psychopathology. In J. Solomon & C. George (eds), Attachment disorganization (pp. 291–317). New York: Guilford Press.
Liotti, G. (2000). Disorganized attachment, models of borderline states, and evolutionary psychotherapy. In P. Gilbert & K. Bailey (eds), Genes on the couch: Essays in evolutionary psychotherapy (pp. 232–256). Hove, UK: Psychology Press.
Liotti, G. (2004a). The inner schema of borderline states and its correction during psychotherapy: A cognitive-evolutionary approach. In P. Gilbert (ed.), Evolutionary theory and cognitive therapy (pp. 137–160). New York: Springer.
Liotti, G. (2004b). Trauma, dissociation and disorganized attachment: Three strands of a single braid. Psychotherapy: Theory, Research, Practice and Training, 41, 472–486.
Liotti, G. & Intreccialagli, B. (2003). Disorganized attachment, motivational systems and metacognitive monitoring in the treatment of a patient with borderline syndrome. In M. Cortina & M. Marrone (eds), Attachment theory and the psychoanalytic process (pp. 356–381). London: Whurr.
Lyons-Ruth, K. (2003). Dissociation and the parent±infant dialogue: A longitudinal perspective from attachment research. Journal of the American Psychoanalytic Association, 51, 883–911.
Lyons-Ruth, K., Yellin, C., Melnick, S. & Atwood, G. (2003). Childhood experiences of trauma and loss have different relations to maternal unresolved and hostile-helpless states of mind on the AAI. Attachment and Human Development, 5, 330-352.
Main, M. & Morgan, H. (1996). Disorganization and disorientation in infant Strange Situation behavior: Phenotypic resemblance to dissociative states? In L. Michelson & W. Ray (eds), Handbook of dissociation (pp. 107–137). New York: Plenum Press.
Safran, J. & Segal, Z. (1990). Interpersonal process in cognitive therapy. New York: Basic Books.
Salkovskis, P.M. (1985). Obsessional-compulsive problems: A cognitive-behavioral analysis. Behaviour Research and Therapy, 23, 571–584.
Steele, K., Van der Hart, O. & Nijenhuis, E.R. (2001). Dependency in the treatment of complex posttraumatic stress disorder and dissociative disorders. Journal of Trauma & Dissociation, 2, 79–115.
Tomasello, M. (1999). The cultural origins of human cognition. Cambridge, MA: Harvard University Press.
Tomasello, M., Carpenter, M., Call, J., Behne, T. & Moll, H. (2005). Understanding and changing intentions: The origins of cultural cognition. Behavioral and Brain Sciences, 28, 675–691.