Chapter 1 discussed the nature of avoidant defenses, such as the use of deactivation as a defense against traumatic distress. Having reviewed such concepts as minimization, idealization, and self-reliance, we now begin to consider what theory and research suggests in regard to intervention. We look at an argument in favor of actively turning attention toward painful attachment-related experiences and challenging defensive avoidance.
Let us examine why such an approach makes sense with this population, why it is important, and why it is not so easy to implement in practice.
Empirical Support for an Approach That Activates the Attachment System
As mentioned in Chapter 1, many difficulties have been documented for clients who tend to use defensive avoidance, and these difficulties have been detailed in the research literature (e.g., Berant, Mikulincer, & Florian, 2001; Edelstein, 2007; Edelstein & Gillath, 2008; Edelstein & Shaver, 2004). Empirical studies have pointed to a host of psychological problems, including negative health-and mental-health-related consequences. In particular, research indicates that avoidant defenses require enormous effort to sustain and are not particularly robust because they are prone to break down in the face of high stress in general and attachment-related distress in particular.
The intervention strategies presented throughout this book are guided, in part, by an approach that addresses the defensive patterns favored by such clients. That is, a treatment approach that activates the attachment system,1 one that turns attention toward attachment-related experiences and challenges defensive avoidance. Without such challenge, the therapist runs the risk of colluding with avoidant coping patterns that may evade distress in the short run yet turn out to be ineffective over time (Bernier & Dozier, 2002; Dozier & Bates, 2004).
There are three bodies of psychological research that point to a general treatment approach that favors activating the attachment system and challenging avoidant defenses. These are presented next.
Unless Deactivation Is Challenged, the Client Will Not Change
Individuals who are avoidant of attachment put considerable psychological effort into closing off discussion of threatening issues. Unless challenged, such issues will likely remain closed off.
Deactivation, as discussed in Chapter 1, is a central defensive characteristic of avoidant attachment. It has as its goal to shift the individual’s attention away from those feelings, situations, or memories that arouse the attachment system. It enables the person to diminish, minimize, or devalue the importance of attachment-related stimuli (George & West, 2001). Experimental studies by researchers Shaver, Mikulincer, and Edelstein (e.g., Edelstein, 2007; Edelstein & Gillath, 2008; Edelstein & Shaver, 2004; Mikulincer, Dolev, & Shaver, 2004), looking at attentional biases, have supported the hypothesis that avoidant individuals turn their attention away from attachment-related material. Importantly, these researchers found that the avoidant participant’s tendency to direct attention away from attachment-related stimuli breaks down when under increased “cognitive load,” demonstrating that deactivation of attachment is a mentally effortful process. That is, avoidant persons turn attention away from issues that activate the attachment system, and such active suppression requires considerable mental effort.
Similar findings have been reported by Dozier and her colleagues (e.g., Dozier & Kobak, 1992), who questioned participants about their attachment-related experiences using the Adult Attachment Interview (AAI; George et al., 1996). They found that, among the avoidant interviewees, there were greater rises in skin conductance, indicating higher levels of anxiety, when discussing attachment-related experiences, despite the fact that they consciously denied feeling distress. Dozier’s findings further corroborate the notion that, for such individuals, the suppression of attachment-related material is a mentally taxing process. In other words, what these experimental studies showed is that avoidance requires considerable effort. Those who are avoidant of attachment work very hard (psychologically speaking) to keep attachment-related issues out of awareness.
Turning to individual psychotherapy, we see that in treatment, attachment-related material is often closed off from discussion (George & West, 2004). What the research just discussed tells us is that defensive avoidance is not easy. It takes a lot of effort to keep attachment-related issues closed off from discussion. Unless challenged, such issues will likely remain closed off, or as is often the case with brighter, analytic individuals, the underlying emotional meaning will remain closed off (Slade, 1999), rendering it impossible to engage in true self-examination in psychotherapy.
In discussing the ways in which attachment theory can help inform clinical practice, Bowlby (1988) stated:
A therapist applying attachment theory sees his role as being one of providing the conditions in which his patient can explore his representational models of himself and his attachment figures with a view to reappraising and restructuring them in the light of the new understanding he acquires and the new experiences he has in the therapeutic relationship. (p. 138)
Bowlby (1988) went on to state that the clinician hopes to “enable his patient to cease being slave to old and unconscious stereotypes and to feel, to think, and to act in new ways” (p. 139). Similarly, psychiatrist David Scharff referred to the field of psychotherapy as the “growth and development business” (Labriola, Carlson, & Kjos, 1998).
In treatment, the continued avoidance of painful attachment-related experiences and events precludes the possibility of helping the client rework problematic models of self and other, and failing to rework representational models of self and other renders the enterprise of psychotherapy less meaningful and long lasting, the unfortunate consequence being an indefinite circling around difficult topics without addressing them substantively. When clients describe psychotherapy as an opportunity “to vent,” something important may be missing from the process.
In discussing avoidant attachment patterns in psychotherapy, Holmes (1997) indicated that as a result of such circling around, therapy sessions may seem vacuous and difficult to recall when writing up notes. In a similar vein, Wallin (2007) referred to the avoidant pattern of attachment as a closed system, and that having learned not to acknowledge or express attachment-related distress, such clients struggle in treatment unless they are met with a more active therapeutic stance.
Researchers in the area of short-term dynamic psychotherapy (e.g., McCullough and colleagues) have referred to “affect phobias” as the fear and avoidance of one’s own emotional responses, such as anxiety, guilt, shame, or fear of rejection (McCullough, 1998, 2001; McCullough & Andrews, 2001). Thus, a number of investigators (e.g., Schore, 2008) have argued in favor of focusing psychotherapy more intensively on affective experiences, with some (e.g., Connors, 1997; Meyer & Pilkonis, 2001) suggesting that treatment of avoidant clients in particular include strategies that facilitate emotional engagement. Interestingly, studies have demonstrated that the greater the ratio of affect to defenses expressed in session, the greater the improvement observed at outcome (McCullough et al., 2001; Taurke, McCullough, Winston, Pollack, & Flegenheimer, 1990). In addition, neurocognitive investigations (e.g., M. D. Lieberman et al., 2007) have begun to lend support to the long-held notion that affect labeling (putting feelings into words) can play a significant role in managing negative emotional experiences.2
With clients who have histories of intrafamilial trauma, we inevitably come across such painful questions as, “If my mother were indeed so loving, why didn’t she protect me from the abuse?” These are questions that have no clear answers but need to be asked nonetheless. As detailed in Chapter 3, there is often anxiety on the part of therapists in hearing and fully addressing painful trauma-related stories. Researchers Cohen, Mannarino, and colleagues have stressed the need for clinicians to become comfortable with listening to such material and with examining the impact of such experiences on the client’s life, noting that even subtle reluctance on the therapist’s part is communicated in the interaction, and that the individual often withholds telling the full story out of fear that the therapist might not be able to tolerate it (Cohen, Mannarino, & Deblinger, 2006; A. Mannarino, personal communication, October 2005).
Consequently, Dozier and colleagues (Bernier & Dozier, 2002; Dozier & Tyrrell, 1998) cautioned against the therapist’s first natural inclination to respond to the avoidance of painful attachment-related topics by “respectfully going along, engaging on superficial, nonthreatening issues” (Bernier & Dozier, 2002, p. 38). Instead, they encouraged a therapeutic stance that “gently challenges” the client’s defensive strategies. Similarly, Dozier and Bates warned of the therapist inadvertently providing confirmatory evidence of the avoidant individual’s worldview. The authors underlined the importance of psychotherapy being oriented toward helping the client “change expectations” (2004, p. 173).
Therapist–Client Dyads With Contrasting Attachment Styles Tend to Work Better
A second body of research, also pointing to a treatment approach that favors activating the attachment system, has arisen from the issue of the client–therapist match in treatment. That is, individuals who are avoidant of attachment appear to do better when paired with clinicians who have a tendency to be much more activating and who challenge their usual relational stance.
Research has begun to explore the match between client and therapist attachment patterns. While only a handful of studies have directly addressed this matter, some initial patterns are beginning to emerge. Increasingly, such studies have been demonstrating stronger effects when clients and therapists relate to one another in a way that is noncomplementary, or contrasting of client expectations (Dozier & Tyrrell, 1998). Studies evaluating adult attachment patterns in therapist–client dyads are beginning to show that therapists and clients with dissimilar attachment tendencies have a greater likelihood for treatment success. Bernier and Dozier (2002) indicated that in such dyads, the dissimilar attachment style of the therapist makes it more likely that she will take on a stance that runs counter to what the client pulls for, consequently disconfirming client expectations and perceptions.
In one study, Bernier and colleagues administered the AAI to counseling dyads in an academic setting. They found support for the noncomplementary hypothesis, using both objective and subjective measures of outcome, such that for students who were avoidant of attachment, the most effective matches were with counselors who valued relationships, connectedness, and interdependence (Bernier & Dozier, 2002). In a similar study, Tyrrell, Dozier, Teague, and Fallot (1999) found that for psychiatric patients and their case managers—all of whom had been administered the AAI—better results were reported for the noncomplementary dyads. Of relevance here, patients considered to be avoidant worked significantly better and demonstrated better outcomes when paired with clinicians who were more activating of attachment.
It is important to note that among the few investigations to date on attachment patterns in treatment dyads, none has been conducted specifically on clients with significant histories of intrafamilial trauma. The Tyrrell et al. (1999) study did look at patients with serious psychiatric disorders, many of whom were diagnosed with varying degrees of depression and comorbid substance abuse disorder. But as noted by Bernier and Dozier (2002), considerably more research is needed on the role that noncomplementarity of attachment plays among client and therapist in psychotherapy.
What is also unclear at this point is the full range of factors that may give some therapists the capacity to adjust their style of attachment-activation depending on the particular needs of the client. Mallinckrodt and colleagues described this process as the therapist systematically regulating the level of emotional distance in the relationship to create a corrective emotional experience relative to the client’s attachment pattern (Mallinckrodt, 2000; Mallinckrodt, Porter, & Kivlighan, 2005). Some theorists (e.g., Dozier & Bates, 2004) have suggested that securely attached clinicians are likely in the best position to make such adjustments. Indeed, Dozier, Cue, and Barnett (1994) found that secure clinicians demonstrated the greatest flexibility and were the most likely to adjust their style of intervention to provide noncomplementary responses to clients. This ability to regulate emotional distance in the relationship may be, in part, what allows securely attached clinicians to be in the best position to negotiate significant challenges to the therapy, such as ruptures within the therapeutic relationship (Meyer & Pilkonis, 2001).
Despite limitations, the research conducted to date does initially suggest that for clients who are inclined to defend against attachment-related distress through the use of avoidance, improved likelihood for successful outcome may be found with a therapist who is more likely to activate the individual’s attachment system and to present a challenge to the client’s usual experience of relationships. This notion is consistent with Bowlby’s (1988) view that a therapist applying attachment theory provides an environment within which the individual can learn to feel, to think, and to act in new ways within the interpersonal world.
Deactivation Turns Out to Be a Poor Means of Coping
A final body of research that points toward activating attachment and challenging defensive avoidance comes from the examination of defensive breakdown. Specifically, the defensive strategy of deactivation, favored by clients who are avoidant of attachment, is prone to break down under high stress and is associated with significant health-and mental-health-related costs. Consequently, helping individuals build healthier patterns of coping and relating may yield tangible, meaningful benefits.
Researchers examining the development of psychopathology across the life span have found that the defenses used by avoidant individuals become ineffective when the person is under high levels of situational stress, particularly stress that is attachment related. That is, deactivation may work adequately as a defense when psychological demands are minimal. However, in more demanding contexts, such as attachment-related stressful life events (e.g., life-threatening illness, birth of a child, divorce), avoidant defenses become incapacitated and tend to break down (Edelstein & Shaver, 2004; Mikulincer & Shaver, 2003).
Evidence that avoidant defenses dissolve under conditions of attachment-related distress can be found in the experimental and naturalistic investigations of Mikulincer and colleagues (e.g., Mikulincer et al., 2004; Mikulincer & Florian, 1998; Mikulincer & Shaver, 2003). In one particularly compelling study by Mikulincer and Florian (1998), the authors showed that deactivating coping patterns (e.g., ignoring, distancing, not seeking social support) were linked to subsequent psychosomatic symptoms attributable to stress in survivors of Scud missile attacks. Similar findings have emerged in studies of maternal reactions to the birth of a child with congenital heart disease (Berant et al., 2001) and in clinical case studies (Sable, 2000). Interestingly, some of the Mikulincer studies (e.g., Mikulincer et al., 2004) have even shown that once avoidant defenses begin to break down, characteristics of poor underlying self-image begin to emerge, that is, negative views of self that are usually masked by defensiveness. The positive self-image that avoidant individuals normally claim to have is therefore fragile (Shorey & Snyder, 2006) and “appears to lack balance, integration, and inner coherence” (Mikulincer, 1995, p. 1212).
Consistent with findings on defensive breakdown under conditions of high stress, a number of researchers have found negative consequences for well-being over time (Shedler, Mayman, & Manis, 1993). Empirical studies in developmental psychopathology and health psychology have demonstrated associations between higher levels of avoidance and subsequent increases in depression (Edelstein & Gillath, 2008) as well as associations between emotional suppression and risk for the development of cardiovascular disease (Mauss & Gross, 2004) and elevations in blood pressure (Jorgensen, Johnson, Kolodziej, & Schreer, 1996). Research by Edelstein (2007) demonstrated that among avoidant individuals, active inhibition of attachment-related material is predictive of increased psychopathology over time, suggesting that the use of defensive avoidance has long-term psychological costs.
Clinicians working in therapy with children who have been abused or neglected have made similar arguments. For example, Eliana Gil (2006) indicated that although suppression of trauma-related material may provide temporary relief, it requires sustained efforts to maintain, will not allow for the understanding required to achieve normative functioning, and will collapse over time.
In a detailed review, Shedler et al. (1993) concluded that the process of inhibiting thoughts and feelings entails physiological work, reflected in the short run in autonomic reactivity and in the long run in increased health problems. Interestingly, the results of empirical research are highly consistent with the position advanced by Bowlby (1980) in his analysis of defensive exclusion and the extent to which it is associated with behavior that is biologically adaptive. Bowlby considered it to be, ultimately, a handicap in dealings with others, leading to ineffective coping with the interpersonal environment and to breakdowns in functioning over time.
In summary, prior research points to significant health and mental health-related consequences associated with defensive avoidance and indicates that the defensive process of deactivation is highly effortful and prone to break down in the face of high stress in general and attachment-related distress in particular. Prior research is also suggestive of a general treatment approach that runs counter to the defensive strategy favored by such individuals, namely, an approach that is challenging of defensive avoidance and therefore disconfirming of client expectations and perceptions.
Why Activating Attachment and Challenging Defensive Avoidance Is Not So Easy
As described, the development of specific intervention strategies for this clinical population has been slow. Although there is much written about the frustrations of working with such clients, there is far less that can be used to guide treatment. In part, this may be because avoidance is so hard to address. Activating attachment and challenging defensive avoidance is not so straightforward. For one thing, individuals who have histories of trauma, but who use defensive avoidance, present a powerful paradox early in the treatment process, making intervention complicated. They are ambivalent about engaging in therapy, so they pull the therapist in opposing directions, making it hard to work with them.
The Treatment Paradox
When coming for psychotherapy, individuals with histories of intrafamilial trauma are often polysymptomatic. Intrafamilial trauma is now known to be associated with a host of psychological factors and mental health challenges that place the individual at risk for the development of psychopathology across the life span (Briere, 1988; Muller et al., 2004; Stovall-McClough & Cloitre, 2006). Yet, those who are avoidant of attachment also demonstrate the tendency to be highly help rejecting, defensive, and minimizing. Horowitz (1976, 2001) described the appearance of denial and general emotional numbness that follow traumatic events for many such clients. Despite a psychological vulnerability that arises from a history of trauma, these individuals put forth significant defensive efforts to maintain a view of self as strong, independent, self-reliant, and normal.
These opposing factors converge to put the client—and therefore, the therapist as well—into a dilemma: Considering and talking about traumatic events flies in the face of defensive avoidance. Yet, failing to recognize one’s history flies in the face of reality.
In treatment, when the therapist makes empathic statements recognizing how difficult or painful a particular experience must have been, the comment is quickly dismissed with brittle, cavalier denial (Wallin pointed out that such individuals often experience empathic statements as “lame substitutes for ‘real’ help” 2007, p. 213). Yet, when the clinician is pulled in the direction of keeping things light, she becomes complicit in the act of minimizing traumatic events, failing to provide the client with a psychologically safe environment within which to explore painful life experiences.
In her seminal work, Trauma and Recovery, Judith Herman (1992) described the “central dialectic of psychological trauma” as the conflict between the will to deny traumatic events and the will to proclaim them aloud. She explained that while there is a strong will to bury atrocities, denial is but a temporary solution; ghosts surface eventually. She viewed the process of remembering and truth-telling to be critical to the healing process. However, much of the time, the desire to bury the truth, to cope with events through a climate of secrecy—indeed to be coerced into secrecy by those in positions of authority—means that truths tend to surface not as clear verbal narratives but as symptoms.
Both clinical wisdom and prior empirical research (e.g., Alexander, 1992) on the effects of intrafamilial trauma point to the detrimental effects of sweeping traumatic events under the rug. Previous trauma theorists have described the countertransference that emerges with such individuals as the tendency to engage in a “mutual avoidance” (Alexander & Anderson, 1994) that provides relief for both therapist and client (Davies & Frawley, 1994). However, to minimize the importance of such experiences is to be complicit in the act often committed by the parent bystander, that is, replication of the failure to protect. In so doing, the therapist fails to provide a context for the exploration of painful life events. Furthermore, failing to help clients face their traumatic experiences also means colluding in a game of pretend. And psychotherapy, without honesty, amounts to very little.
In describing the fundamental premise of the psychotherapeutic work as a belief in the “restorative power of truth-telling,” Herman (1992) wrote:
From the outset, the therapist should place great emphasis on the importance of truth-telling and full disclosure, since the patient is likely to have many secrets, including secrets from herself. The therapist should make clear that the truth is a goal constantly to be striven for, and that while difficult to achieve at first, it will be attained more fully in the course of time. (pp. 148, 181)
Grounding Treatment in a Secure Therapeutic Relationship
So far in this chapter, we have considered a general treatment approach that favors activating attachment and challenging defensive avoidance. As described, unless such challenges occur, the clinician runs the risk of colluding with defensive coping patterns that may avoid emotional distress for a short while but in time will turn out to be detrimental for the individual. We have reviewed research on the topic, most of which lends support to this approach. However, we have noted that activating attachment and challenging defensive avoidance is not so straightforward. Clients who have histories of trauma, but who use defensive avoidance, present a powerful paradox early in the process. As stated, they are ambivalent about engaging in treatment and therefore pull the therapist in opposing directions, making it complicated to work with them.
There are other reasons why challenging defensive avoidance can be difficult. For the therapist who places a high premium on the importance of the therapeutic relationship, a more activating, challenging approach can present a variety of problems. In my experience, most therapists working with trauma survivors value the therapeutic relationship, namely, the establishment of security, safety, and a climate of empathy; so understanding how to balance the “secure base” of the therapeutic relationship against the complexities inherent in challenging defensive avoidance reflects both skill and artfulness in the therapy. Let us here consider the importance of the therapeutic relationship in the treatment of trauma and then the complications to the relationship that arise out of a more activating therapeutic stance.
With clients who have experienced suffering at the hands of the important people in their lives, the centrality of the therapeutic relationship to the healing process cannot be emphasized enough.3,4 Liotti (2004), who has written extensively on attachment and the psychotherapeutic relationship, explained that when clinicians are developing treatment priorities in their work with clients who have trauma histories, striving for safety and alliance within the therapeutic relationship should take precedence. In a similar vein, Pearlman and Courtois (2005) emphasized the importance of the therapeutic relationship with such high-risk clients, explaining that the relationship should be marked by respect, information, connection, and hope. In their approach to treatment, the development of a secure therapeutic relationship gives rise to opportunities to examine views of self and other and to build interpersonal and self-regulation skills.
Other attachment theorists have espoused similar approaches to intervention. Drawing on Bowlby’s (1988) concept of the secure base in treatment, Jeremy Holmes (2001) discussed the critical importance of responsiveness and empathic attunement in the psychotherapeutic relationship:
A secure base arises out of the responsiveness and attunement provided by the therapist. Attunement is, by its very nature, non-controlling, following rather than leading, affective rather than instrumental. It is “aimless” in the sense that it cannot legislate in advance for what will emerge from the playful and spontaneous encounter between therapist and patient…You cannot prescribe what is going to happen in a session…What can be prescribed are the conditions favorable to secure base. (p. 50)
In my own work, and throughout my training, the treatment relationship has always been of central importance. Concepts such as clinician responsiveness, attunement, empathy, and genuineness in the therapeutic interaction are all fundamental treatment ingredients that I value tremendously, ingredients that I see at the heart of growth and development in psychotherapy. Without empathy, without a sense of connection and psychological contact between therapist and client, there can be no therapy.
Clients who have experienced considerable rejection and hurt in their families of origin, rejection that has gone unacknowledged and unresolved, need a safe context within which they are given the opportunity to experience relationships in new ways. When safety and security characterize the therapeutic relationship, such interaction may represent the client’s first occasion to experience support, encouragement, and emotional vulnerability with an empathic other.
Over-Versus Underchallenging the Client
For the clinician who values the therapeutic relationship in the treatment of clients with traumatic histories, challenging avoidant defenses is hard to do. Turning the avoidant client’s attention toward attachment-related issues and patterns can be difficult to manage in a manner that does not strain the therapeutic relationship and does not jeopardize the client’s sense of feeling understood. It is not so easy to challenge defensive avoidance in a manner that is both attuned to the client’s experience and yet not irritating, too much for the client to handle, or appearing as though the clinician were following a personal agenda.
Activating attachment can be difficult to do in practice, to do in a way that values the therapeutic relationship, maintains empathic attunement, and connects with the client rather than overwhelms or controls him. In this chapter, we discussed a sizable body of research, pointing in the direction of challenging defensive avoidance, and we discussed a number of reasons why such an approach is thought to be effective. But, in practical terms, how does one do so without jeopardizing the therapeutic relationship?
When making attempts to challenge defensive avoidance, it is easy to fall into a pattern in which the clinician, acting on his countertransference, particularly feelings of frustration with the client’s defensiveness, becomes overly keen and aggressive and in the process overchallenges the individual. Out of such interchanges arise empathic failures and ruptures in the therapeutic alliance, along with temporary increases in symptomatology and possibly retraumatizing interactions. The client feels misunderstood and frustrated and becomes all the more convinced that therapy is not for him. And, because his pattern of dealing with relational distress is to minimize, he may not even be aware of or communicate feelings of dissatisfaction to the clinician, opting instead not to show up for subsequent appointments and then to convince himself that “things are just too hectic right now for therapy,” burying feelings about the interpersonal conflict in the process. Therefore, an important aspect of the work with this population is in challenging defensive avoidance and activating the attachment system but at a pace that the client can tolerate. That is, gauging the individual’s level of anxiety and working at a level that his anxiety can bear.
Of course, when empathic failures occur (and they invariably do), they can actually provide useful—albeit painful—opportunities for growth. For the client, the opportunity to discuss how he felt misunderstood by the therapist may present one of the first times he has actually taken such an emotional risk with anyone, perhaps expressing feelings, positive and negative, that he never before felt comfortable expressing. Naturally, this sort of interchange can only occur if the therapist has done the alliance-building work early in the treatment, is in the habit of recognizing countertransference, is open to noticing how her own behavior may have hurt rather than helped the client in the previous sessions, and in a nondefensive way is inclined to open up discussion of such relationship ruptures in subsequent sessions.
Thus, overchallenging the client represents a potential pitfall in attempting to activate attachment and challenge defensive avoidance. Similarly, an emphasis in the other direction, in which the clinician is overly cautious, can be problematic in its own right. And, the clinician may fall into a pattern that underchallenges the client.
Lifelong patterns of avoidance are powerful, and the therapist working with any individual in emotional distress, especially one with a high-risk history, is repeatedly pulled in the direction of “not imposing,” not wishing to further the client’s pain. The pressure not to discuss the elephant in the room can be powerful. In both the clinical literature and practice, therapists tend to characterize working with clients who avoid attachment as a stressful, laborious experience. Sessions may seem emotionally anemic, or dull to sit through, as the client may wish to discuss anything but the issues that make her feel so vulnerable. The therapist may experience the hour as “empty” or “like pulling teeth,” often circling around matters that appear to lack substance or repeatedly finding questions or interventions stifled and dismissed.
When questions or empathic comments are repeatedly shut down or when individuals insist on discussing issues that lend themselves to less distress, a common tendency is to accommodate.5 This is natural. If not, the interaction would feel awkward, and conversation would not flow. However, the consequence of such accommodation is a co-constructed avoidance, one of which the therapist may or may not be aware. Importantly, some have argued (e.g., Steiner, 1993) that when there is too much of this kind of accommodation, the client may come to see the therapist as having given up or as feeling defeated. Or, the client may pick up on the dishonesty inherent in such a collusion.
For the therapist, the ability to catch himself overchallenging or underchallenging the client is a difficult but important aspect of treatment. There is a fine line to walk between these two alternatives. And, the ability to find that line is often a function of therapist countertransference. Over the next few chapters (Chapters 3, 5, and 6), we discuss similar issues that arise within the therapeutic relationship, issues that relate to both transference and countertransference.
Chapter 3 begins to examine specific approaches to intervention with this clinical population; some of these approaches I have described elsewhere (e.g., Muller, 2006, 2007, 2009; Muller, Bedi, et al., 2008). Bowlby (1988) stated that the therapist applying attachment theory helps the client explore representational models of self and of attachment figures with a view to reappraise and restructure them in light of new understanding. He acknowledged that the process can be a painful and difficult one, requiring the therapist to aid the individual in considering ideas and feelings about important others that had been previously regarded as unimaginable.
Summing Up
How do we guide our approach to treatment if we expect to work from the standpoint of attachment theory and research?
In the beginning of this chapter, we described the three bodies of psychological research that point to a general treatment approach that favors activating the attachment system and challenging defensive avoidance. First, we discussed how individuals who are avoidant of attachment put considerable psychological effort into closing off discussion of threatening issues, and that unless we challenge deactivation, such issues will likely remain closed off. Next, we examined research findings on so-called noncomplementarity of attachment within clinician–client dyads in counseling relationships, and discussed studies that showed that clients who are avoidant of attachment do better in treatment when paired with therapists who have a bent toward a more activating pattern of attachment. Last, we looked at the phenomenon of defensive breakdown and noted how, among clients avoidant of attachment, defensive strategies such as deactivation are prone to fall apart when the individual is under attachment-related stress, and that such defenses are therefore associated with substantial health-and mental-health-related costs to the client.
In the second part of this chapter, we talked about how, practically speaking, it is not so easy to activate attachment and challenge defensive avoidance. We described a treatment paradox among such individuals. On one hand, we find a highly symptomatic presentation consistent with the client’s high-risk history. On the other, we find a tendency toward help-rejecting defensiveness. In practice, the therapist ends up being pulled in opposing directions, toward acknowledging and focusing on client traumatic distress but, paradoxically, toward minimization and mutual avoidance of trauma as a way of accommodating to client expectations.
Mixed feelings about addressing traumatic experiences are inherent in the treatment paradox. Stemming in part from the client but transmitted to the therapist, such mixed feelings can pull the clinician into overchallenging or underchallenging the individual or even into a cycling back and forth, sometimes pushing too aggressively but sometimes sweeping traumatic events and attachment-related distress under the rug. So, when we consider the complexities of challenging defensive avoidance, we note that it is not always easy to do in a manner that protects the therapeutic relationship and keeps a healthy empathic connection between therapist and client. When we find this balance, we take part in a healing that is not only secure and safe but also honest.