Psychotherapy: Theory, Research, Practice, Training
? 1994 by the American Psychological Association Volume 31(4), Winter 1994, p 665?675
AN ATTACHMENT APPROACH TO PSYCHOTHERAPY WITH THE INCEST SURVIVOR
ALEXANDER, PAMELA C.1,3; ANDERSON, CATHERINE L.2
2Northwest Center for Mental Health.
3Correspondence regarding this article should be addressed to Pamela C. Alexander, University of Maryland, Dept. of Psychology, College Park, MD 20742-4411.
By focusing on the nature
of the parent-child relationship, attachment theory provides a framework
for understanding the wide array of symptoms and interpersonal problems
exhibited by adult survivors of incest. While the relevance of attachment
theory to the therapeutic process has been explored in general, there
have been few systematic descriptions of the four main categories of
adult attachment (secure, preoccupied, dismissing, and fearful/ unresolved)
with respect to their anticipated effects in the therapy relationship.
Based on current research on adult attachment and clinical impressions
of incest survivors, this article presents the probable therapeutic
issues (including transference and counter transference) associated
with each attachment category as well as suggested therapist strategies
for dealing with clients from each attachment category. Case studies
are included.
The past few years have seen the development of a number of specific abuse-focused and PTSD approaches to therapy with incest survivors (cf. Briere, 1989; Courtois, 1988; Gil, 1988; Herman, 1992). While these perspectives have been useful and appropriate for many sexual abuse survivors, many other clients experience incest as only one of many types of abuse, rejection, and trauma perpetrated by their families. We know, for example, that sexual abuse seldom occurs in a vacuum but instead co-occurs with other types of abuse and neglect which have their own distinct effects (Briere & Runtz, 1990). Furthermore, for many abuse survivors, the family context associated with the abuse explains even more of the long-term effects than the abuse itself (Edwards & Alexander, 1992; Friedrich et al., 1987; Harter et al., 1988; Peters, 1988). Therefore, for a large number of incest survivors who experienced the abuse within the context of rejecting, neglectful and abusive parent-child relationships, a therapy approach focused specifically on the sexual abuse misses much of the client's most pervasive experiences of loss, rejection, and abandonment experienced within the family (Haakan & Schlaps, 1991). For these incest survivors, the following approach to treatment, based on an attachment perspective, promises to be a useful alternative to a more specific incest-specific approach.
Attachment theory, as proposed by Bowlby (1969/1982), states that the original parent-child relationship is of as much importance for the survival of the child as are eating and sleeping. Based on the response of the parent to the child's expression of need, the child develops an ?internal working model? of relationships consisting of expectations about self and other and including both affective and cognitive components (Bowlby, 1969/1982). As noted by Zeanah & Zeanah (1989), the internal working model ?governs how incoming interpersonal information is attended to and perceived, determines which affects are experienced, selects the memories that are evoked, and mediates behavior with others in important relationships? (p. 182).
For example, the child who learns mat his/her clear communication of negative affect leads to an appropriate responsiveness on the part of the parent develops a secure ?primary? strategy of attachment (Main, 1990). This secure child uses the parent as a secure base to explore the environment, develops an effective method of self-soothing and affect regulation, and comes to see him/ herself as worthy and deserving of attention and others as responsive and trustworthy. The secure child, not surprisingly, has been found to be more popular, empathic, and resourceful than others (Sroufe, 1988). Conversely, the resistant child whose negative affect is responded to inconsistently and with role-reversal develops an insecure attachment strategy of exaggerating the negative affect (Izard & Kobak, 1991). This child's cognitive template of self as unworthy and undeserving of the attention of others explains the tendency to be more needy, tense, impulsive, passive, and vulnerable to victimization by other children (Sroufe, 1988; Troy & Sroufe, 1987). The avoidant child learns that his/her negative affect is responded to with rejection and therefore develops the strategy of inhibiting negative affect so as to not elicit even more rejection from the attachment (Izard & Kobak, 1991). The avoidant child has been found to be less empathic and more hostile or antisocial than other children (Sroufe, 1988).
Finally, the disorganized child exhibits no coherent strategy for maintaining proximity with the attachment figure when stressed (Main & Hesse, 1990), instead showing such contradictory approach/avoidant behaviors as moving toward the parent with his/her head averted, extreme protest upon separation from the mother followed by active avoidance upon her return, slow movements, freezing, dazed expressions, and apprehension toward the parent (Main & Solomon, 1986). The disorganized child appears to be in the untenable position of simultaneously needing to approach and avoid the parent who seems to be both the source of and the solution to the child's problems (Main & Solomon, 1986). As Main & Hesse (1990) noted, the parent of the disorganized child appears frightened and/or frightening to the child, perhaps in reaction to their own history of traumatic loss or sexual abuse. The disorganized child later becomes either parentified and controlling of the parent or depressed, disorganized, and frequently dysfluent (Main & Cassidy, 1988; Main et al., 1985). While no studies to date have been conducted specifically with sexually abused children, disorganized children have been found to predominate along with resistant and avoidant children in samples of physically abused or neglected children (Carlson et al., 1989; Egeland & Sroufe, 1981; Schneider-Rosen et al., 1985).
Changing life circumstances, a change in the attachment figure, and developmental changes may alter attachment patterns (Bremerton, 1985). However, the fact that internal working models tend to remain outside conscious awareness increases their resistance to change (Bremerton, 1985). Main & Cassidy (1988) have demonstrated the stability of these internal working models from infancy to six years of age, although longitudinal studies of attachment from childhood into adulthood remain to be conducted. However, the construct of adult attachment has been validated by its ability to predict the attachment of the adult's children (Main & Gold-wyn, 1984). It has also been correlated in theoretically prescribed ways with measures of anxiety, interpersonal functioning in intimate relationships, psychophysiology, and parenting behavior (Collins & Read, 1990; Dozier & Kobak, 1992; Feeney & Noller, 1990; Haft & Slade, 1989; Hazan & Shaver, 1987; Kobak & Sceery, 1988). While attachments in adulthood differ in some ways from those in childhood, they still represent the need for adults under conditions of stress to seek proximity with the primary figure as a way of seeking comfort and security (Ainsworth, 1989; Weiss, 1991).
Four primary adult attachment styles have been postulated comparable to the four primary attachments of childhood, although the nomenclature used by researchers of adult attachment differs from that used to describe the attachment of children. These include secure attachment (comparable to that of the secure child), preoccupied attachment (comparable to that of the resistant child), dismissing attachment (comparable to that of the avoidant child), and fearful/unresolved attachment (comparable to that of the disorganized child). Each of these adult attachments will be described in greater detail below. It is proposed that by understanding the experience of the secure child, the resistant child, the avoidant child, the disorganized child, and each of their adult counterparts, therapists can be more sensitive and attuned to the client's view of self and others and can also be more effective in interrupting the inter-generational transmission of abuse.
Attachment theory is pertinent to the study of incest for several reasons. First, it is consistent with Finkelhor's Four Preconditions model of abuse (Finkelhor, 1984), which focuses on the motivation to sexually abuse, internal inhibitors within the perpetrator, external inhibitors by the nonoffending parent, and the child's resistance. As such, it can help explain the dynamics in the perpetrator and the nonoffending parent and the vulnerabilities in the child that help set the stage for abuse (Alexander, 1992). Second, attachment theory can describe the diverse ways in which sexual abuse can be experienced?as role reversal and parentification, as rejection, and as fear and unresolved trauma (Zeanah & Zeanah, 1989). Third, attachment theory can explain an individual's approach and/or avoidance of the parent and, through the internal working model, of intimate relationships in general.
Finally, attachment theory can be used to explain the diverse array of negative outcomes in incest survivors. For example, Alexander et al. (1993; Alexander, 1993; Anderson & Alexander, 1994) used a structured interview format and self-report measures to assess the adult attachment and outcome of 112 adult female incest survivors. Whereas abuse characteristics explained specific post-traumatic stress disorder (PTSD) symptoms, state of mind regarding attachment explained distress, depression, and personality structure. Secure individuals exhibited fewer symptoms. Preoccupied individuals showed the highest rate of dependent personality disorder as well as increased rates of avoidant, self-defeating, and borderline personality disorders. Consistent with their suppression of negative affect, dismissing individuals reported the least distress of all. Finally, fearful/unresolved individuals showed the most distress as well as the greatest likelihood of avoidant, self-defeating, and borderline personality disorders. In addition, they were significantly more likely to exhibit dissociation (Anderson & Alexander, 1994). Therefore, attachment seems particularly germane to the most intransigent symptoms and personality structures exhibited by incest survivors in therapy.
While most studies of adult attachment have focused on intimate romantic relationships or the relationship with one's own child, another important attachment relationship in adulthood is developed in psychotherapy (Dolan et al., 1993). By bringing to the therapist the fears and anxieties associated with other important attachment relationships, the client acts out his/her internal working model through the process of transference and attempts to fit the therapist to that unconscious working model (West et al., 1989), The goal of therapy from an attachment perspective is one of helping the client increase the ?permeability. ANd complexity of these working models by revising them both cognitively and affectively on the basis of new information (West et al., 1989), in other words, to move increasingly toward a secure state of mind. However, as opposed to a reliance upon specific techniques more common to cognitive/ behavioral therapy, the emphasis is on a relationship-based approach to change (McMillen, 1992). The therapist's function as a ?secure base? (Bowlby, 1988) is not dissimilar from Winnicott's (1965) concept of a ?holding environment.? From this secure base the client is invited to explore the inner world of past, current, and transferential attachment, separation, and loss experiences (Sable, 1992). The therapist thus helps the client ?sort through [her] family story, affirming responses to the situations described, encouraging where there is reluctance [resistance] to recall memories and feelings and clarifying where events have been misconstrued? (Sable, 1992, p. 280). In addition, the therapist helps the client mourn losses, including the summative effects of many experiences of parental rejection or nonresponsivity (West et al., 1989). Other issues, such as the stages of therapy, the effect of the therapist's security of attachment, or the effects of gender on attachment, or on the therapist-client interaction, remain to be studied.
Furthermore, while the general relevance of an attachment perspective for understanding this process of therapeutic change has been explored, there have been few systematic descriptions of the four specific adult attachment classifications (secure, preoccupied, dismissing, and fearful/unresolved) with respect to their anticipated effects in the therapy relationship. This article attempts to present a rationale for the utility of an attachment perspective for conceptualizing the probable therapeutic issues (treatment issues, transference, and countertransference) associated with each attachment classification as well as suggested therapist strategies for dealing with clients with each attachment classification. Current research on adult attachment as well as our clinical impressions of the 112 incest survivors who participated in the structured interview study of attachment described earlier (Alexander, 1993; Alexander et al., 1993; Anderson & Alexander, 1994) provide the basis for this article. In addition, case illustrations are included to illustrate the initial presentation and therapeutic process associated with each attachment classification.
The therapeutic issues described below are not unique to incest survivors, although our examples refer primarily to this population. Furthermore, while the following comments apply to male clients as well as to female clients, our continuing reference to our sample of female incest survivors is the basis for our use of the feminine pronoun. Finally, it is to be expected that most clients have characteristics of more than one type of attachment. The following clinical descriptions make use of prototypes to illustrate how adult attachment styles can be used as an organizing construct in working with the variety of presentations of incest survivors in therapy.
The individual with a secure state of mind is not exempt from experiencing distress and occasionally needing or making use of psychotherapy. However, her generally effective strategy for regulating affect, which includes self-soothing and making use of current attachment relationships and social supports, allows her to approach therapy from a very different perspective than individuals from the three types of insecure attachment to be described further.
Research on the adult with a secure working model of attachment (comparable to the secure child) suggests that she is relatively self-confident, trusting, moderately proximity-seeking, expressive, more effective at resolving conflict, and tends to have longer and more satisfying relationships (Brennan & Shaver, 1991; Collins & Read, 1990; Feeney & Noller, 1990; Hazan & Shaver, 1987; Pistole, 1989). However, especially among incest survivors, her childhood was obviously not as supportive and problem-free as that of most securely attached individuals. In fact, she may well have initially presented in therapy as insecurely attached. As a result of her progress in therapy, she may currently be approaching remaining issues from a secure perspective. Alternatively, her past insecure attachment may have been modified and altered by a supportive relationship with a secure partner (Conn et al., 1992).
In any case, whether presenting with a developmental or existential issue, the secure client's reason for seeking therapy is usually in perspective. She may be distressed by the issue, but she is nevertheless able to place it in context. Interpersonally, she is able to tolerate the therapist's humanity and has good access to social supports outside of therapy. In contrast to other clients, she is less likely to vilify or adore either the therapist, others in her life, or her past memories of childhood. With her perspective and access to both positive and negative feelings, the secure individual is able to fully acknowledge the realities of the abuse and anger toward the abuser, to replace self-blame with self-compassion, to take a more proactive stance relative to the abuser, and to view the abuser as a complex person rather than in stereotyped and simplistic terms.
Thus she is able to hold and examine contradictory feelings, inconsistent behaviors on the part of herself and others, and different points in time. She is able to acknowledge distress in the past or present and still be aware of a more positive future. She is more willing to approach a therapeutic issue with a sense of curiosity rather than impending doom. Consequently, she is able to tolerate more psychological distress in therapy, and is able to work harder, faster, and more consistently than other clients. In fact, as psychotherapy outcome research both in general and specifically with incest survivors has consistently demonstrated, individuals with greater psychological resources (i.e., secure attachment) are much more able to profit from therapy than clients with fewer emotional resources (Follette et al., 1991; Luborsky et al., 1988). Therefore, this client is able to use her secure attachment to come to an even better understanding of her current and past attachment relationships.
Brenda was a woman in her early 30s who presented around the serious illness of her parents, who had physically and sexually abused her during childhood. Based on anecdotal information, the therapist inferred that Brenda had moved from a more preoccupied stance to increased security as a function of both previous therapy (in which she had confronted both her parents about their roles in her sexual abuse) and a marriage to a presumably secure supportive spouse. Her current goal in therapy was to address some of her estrangement from her parents in an attempt to bring more closure to that relationship. Brenda had renewed relationships with some of her siblings. She was very proud of her ongoing ability to balance the clear placement of responsibility on her parents for their roles in her abuse, while also attempting to understand the influences that acted on each of them (e.g., early childhood trauma, alcoholism, and job stresses). However, although she was able to achieve this balance while out of contact with them, she was concerned about the feelings that might emerge if she began to actually meet with them. As she anticipated their impending deaths, she had decided that she wanted to be able to talk face-to-face with her parents without either feeling consumed by her rage or denying the reality of their abusive behavior in her life.
Brenda was able to acknowledge the impact of her own history in its entirety, including both the mourning of some of her early choices, such as abusive early relationships, adolescent promiscuity, and drug abuse, and the celebration of her current friendships, relationships with her husband and children, and job successes as an editor. She was thus able to use the process of the therapeutic alliance to clarify the remaining issues resulting from her relationship with her parents (such as hypersensitivity to criticism and difficulty with assertiveness) and was able to engage transferentially in the articulation and negotiation of her needs.
Just as the resistant child clings to the parent and exaggerates affect in order to take advantage of the intermittent responsiveness of her inconsistent parent, the adult classified as preoccupied similarly clings to and actually cannot escape attachment-related memories and concerns. She is reminiscent of the incest survivor described by Silver et al. (1983) who ruminates incessantly about the abuse in an attempt to make sense of her abuse experience. Unfortunately, it is not clear that this cycle of searching for meaning followed by distress followed by even more ruminations necessarily results in resolution. For example, Silver et al. (1983) noted that over half of their subjects who were actively searching for meaning twenty years after the abuse had ended described themselves as completely unsuccessful in making any sense of their experience. Thus the strategy of holding on to these memories provides no more relief or sense of security for the preoccupied adult than did clinging to the parent provide for the resistant child.
Research on adult attachment provides similar information regarding the effects of this desperateness in the adult with a preoccupied working model. She tends to express less self-worth, assertiveness, and sense of control, to be indiscriminately self-disclosing (which especially increases the vulnerability of incest survivors), to have more self-doubts, to feel misunderstood and underappreciated, and to be more lonely (Collins & Read, 1990; Hazan & Shaver, 1987; Mikulncer & Nachshon, 1991). In romantic relationships, she is more likely to be characterized on self-report measures as clinging, jealous, obsessive, dependent, self-sacrificing, alternately idealizing and easily frustrated with her partner, and to describe love as a series of emotional highs and lows characterized by extreme sexual attraction (Brennan & Shaver, 1991; Collins & Read, 1990; Feeney & Noller, 1991; Hazan & Shaver, 1987). From this list of descriptors, it can be anticipated that the initial presentation of the preoccupied client would be one of helplessness, desperation and dependency.
Several important attributes of the resistant child's family experience can help explain the client classified as preoccupied. Her family was characterized by boundary confusion and role reversal. Not only is she still likely to be engaged in an enmeshed relationship with her parents (Mikulncer & Nachshon, 1991), but her compulsive need for attachment would also be expected to emerge in the therapeutic relationship, alternating between idealization of the therapist and a reaction of rage and hostility when needs are not met to her satisfaction. As in the client's family of origin, boundary problems may take the form of triangulation?with the therapist and a partner, with the current therapist and a past therapist, and in a group therapy setting, between different members of the group.
As mentioned previously, the resistant child's strategy for maintaining access to an inconsistent parent was to heighten affect (Main, 1990). This strategy of dealing with anxieties will necessarily occur in the therapeutic relationship as well. Furthermore, the exaggerated affect combined with a tendency for role reversal and emotional dependence makes the client with a preoccupied working model more vulnerable to revictimization. As one incest survivor in our sample stated, ?I idealize others more than myself,. ANd went on to describe several relationships with men and women who took advantage of her in various ways. Another survivor talked about feeling lucky that her physically abusive husband would agree to take her back after he had thrown her out of the house. The preoccupied client's tendency to similarly idealize her therapist makes her vulnerable to an unethical therapist's exploitation and abuse of power in the therapy relationship. Furthermore, this client may respond with even more loyalty to such ill-treatment.
The therapist should be alert to high-risk behaviors that the preoccupied client may exhibit. For example, adults from this classification are more likely to endorse the consumption of alcohol for the purposes of coping with negative feelings and sensation-seeking (Brennan & Shaver, 1991). They may express their anxiety through bulimia (Brennan & Shaver, 1991) and suicidal gestures. While also pertinent to the individual who is fearful/unresolved with respect to attachment, Herman's (1992) discussion of the importance of helping the client attend to issues of safety, reliable self-care, and greater discretion about whom to trust are particularly germane to therapy with the preoccupied client.
Given that current attachment relationships can either maintain or alter internal working models, it is important that the therapist examine his/her reactions to the preoccupied client. In addition to feeling suffocated by the client's adulation, dependency, and fears of abandonment, the therapist is likely to feel overwhelmed by the unremitting quantity of crises and lack of self-protection presented by the client from this classification. The danger, of course, is that the therapist will overreact to this understandable concern through excessive and intrusive care-taking, then reenacting the parent's pattern of retreating and ridiculing out of frustration and then, perhaps out of guilt, reengaging in an overly involved manner. Similarly, this client's family experience can sometimes contribute to a disintegration of boundaries with a therapist whose own history of abuse is unresolved or with a therapist susceptible to sexualization dynamics (Briere, 1989). The therapist thus needs to be clear and comfortable about his/her own boundaries, power, and responsibility in the relationship lest any expression of ambivalence reinforce the client's feelings of rejection. While the therapist must consider the client's high-risk behaviors in terms of danger to self or others, the therapist is not able to control the client's behavior. The eventual goal of this therapeutic stance is to help the client develop her own internalized self-protection.
Tammy was a 32-year-old recovering alcoholic who initially presented with depression and suicidal ideation secondary to parenting problems with her seven-year-old son and to relationship problems with her married lover. She was referred by her son's therapist due to her extreme apparent neediness in parent collateral contacts, which resulted in an inability to focus on her son's issues rather than her own. Additionally, Tammy exhibited role-reversal with her son such as expectations that he independently buy her a birthday card and perform other age-inappropriate tasks such as doing their laundry and buying groceries. Boundary violations which occurred inside of the therapy sessions included Tammy sitting provocatively with her clothing disarrayed. Boundary violations occurring outside the therapy sessions included asking personally intrusive questions of her employer.
Tammy had a childhood marked by severe family chaos, maternal alcoholism, multiple caregivers, and foster placements. Her father, a stern, emotionally withholding man who frequently traveled, only responded affectionately to Tammy in the context of his sexual abuse of her. Despite this, she idealized him and blamed herself for the sexual abuse which she attributed to her ?pestering him all the time.? Tammy was also sexually abused in two of her four foster homes. Her adult history was one of ongoing victimization in interpersonal and employment-related situations, resulting in long periods of underemployment for unappreciative bosses and relationships with withholding, emotionally abusive men. These victimizations would be interspersed with periods of impotent, unpredictable rage, in which Tammy would lash out in ways that caused her to look immature and overreactive. Her constant rumination and preoccupation with her abuse, her PTSD symptoms, and her conditioned phobias inextricably bound her to her self-definition as a ?victim.?
Tammy participated in a long-term group for survivors of sexual abuse and tended to dominate the group with her crises. The press of her own issues would overwhelm her, making it very difficult for her to share tune in the group, to empathize with others, and to sustain her insights from one group session to the next. She also resisted the group's move toward other non-abuse-related issues. She idealized her individual therapist, and would often attempt to elicit a ?rescuing? response by portraying herself as helpless and distraught. The therapist's countertransference was marked by a vacillation between the desire to caretake and anger at Tammy's dependency needs. This process issue was addressed by the therapist's careful attention to boundaries to make sure that this client was not given latitude unavailable to other clients. By observing her own responses to Tammy's requests, the therapist could deal with the pull to care-take or, conversely, to abandon.
The turning point in treatment came when there was a mandatory duty to warn a coworker about Tammy's threats against her. Tammy became enraged at the therapist's decision to react seriously to her verbalized threats. The therapist responded to this therapeutic crisis with support for Tammy's distress while maintaining a firm stance regarding the necessity of duty to warn. Consequently, Tammy slowly began to acknowledge her personal power by taking responsibility for separating her strong feelings from her actions. Thus the therapeutic process for working with the preoccupied client involves helping the client learn strategies for self-soothing without having to resort to such extreme affect.
The adult with a dismissing working model of attachment can best be understood by considering the family experience of the avoidant child. While the parents of the avoidant child were not necessarily consistently rejecting, their coldness and lack of responsiveness were sure to emerge at the point when the child needed help. Haft & Slade (1989) have noted, for example, that the parent of die avoidant child is likely to respond positively to the child's autonomous behaviors but to misattune to the child's requests for nurturance. Therefore, the learned response of the avoidant child is to hold back when feeling needy so as not to elicit even more rejection from the parent. This reluctance to express negative affect becomes internalized and may take the form of compulsive self-reliance (Bowlby, 1969/1982), in which the client's own needs are never expressed or acknowledged, even to herself.
As might be expected, the adult classified as dismissing (comparable to the avoidant child) is uncomfortable with intimacy, not confident about others' availability, highly self-reliant, seen as hostile by others, easily frustrated with partners, and overtly denying of problems while exhibiting covert symptoms of anxiety, distress, and dysfunction (Brennan & Shaver, 1991; Collins & Read, 1990; Feeney & Noller, 1990; Hazan & Shaver, 1987; Kobak & Sceery, 1988; Mikulincer et al., 1990). For example, Dozier & Kobak (1992) found that the tendency for individuals to adopt deactivating (dismissing) strategies was significantly associated with increased physiological arousal precisely at the point in the attachment interview when they were being interviewed about parental rejection and separation. Therefore, the public persona of the dismissing client is an attempt to counter some very real although unconscious feelings of distress.
Given that the dismissing adult tends to downplay or devalue the importance of attachment relationships (Main & Goldwyn, 1984; Main et al., 1985), she is less likely to seek therapy in the first place. However, either the problems of others (a spouse or a child) or a curiosity about therapy could conceivably enlist her initially skeptical participation. As Crittenden et al. (1991) have noted, she will probably present herself as relatively problem-free and even ?more normal than normal.? Her denial of problems and attachment-related concerns is likely to manifest itself in glowing generalizations about childhood which are then contradicted by specific memories, if memories are available at all (Main & Goldwyn, 1984). This client's lack of disclosure thus may not reflect active guardedness as much as an actual lack of access to memories. This pattern of denial and minimization originated in the family of origin and protected the family and the child from the disruption of acknowledging abuse, rejection, and other conflicts (Olio & Cornell, 1993). However, it also makes the survivor susceptible to reenacting the rejection and lack of protection with her family of creation. Therefore, because her perceptions of her own functioning are not necessarily reliable, any opportunity to actually observe her interactions with significant others would be useful and illuminating.
In her interactions with the therapist, the client classified as dismissing may attempt either to discredit, compete with, or assume a superior stance with the therapist. (In a group therapy format, this may prove to be especially challenging for the therapist.) In response to this presentation, several forms of countertransference can be expected to emerge. First, it would not be unusual for the therapist to feel incompetent and defensive about credentials. The therapist may feel indignation at the client's sense of entitlement. Alternatively, the therapist may find him/herself engaging in a type of mutual avoidance with the client resulting either in a sense of boredom with the client's apparent superficiality or in a mutually agreed-upon termination which provides relief for both the therapist and the client.
One useful strategy to adopt in working with this client is the stance of curiosity described by Cecchin (1987) as a way of reconnecting with the client. According to Cecchin, a frame of neutrality and curiosity about the perspectives and ideas of clients (as opposed to a more linear stance of discovering the ?truth?) can help therapists bypass the boredom, power struggles, and moral indignation that frequently emerge when working with difficult clients, of which the client from this classification is exemplar. Furthermore, the therapist is encouraged to remember that the client's pseudo self-confidence is a learned strategy to deal with attachment-related anxieties such as those bound to arise in any therapy relationship. Then, the therapist can attempt to focus on becoming more centered in the room and in the relationship. This will allow the client's anxieties to remain with the client instead of being inadvertently adopted by the therapist. Only by actually feeling the painful emotions in a supportive nurturing environment can the client begin to reclaim her sorrow and anger arising from her parent's rejection of her.
Christina was a 48-year-old woman who came to therapy complaining of chronic severe nightmares which were only partially alleviated by Prozac?. She denied any other overt distress. She was divorced, with a college-aged daughter about whom she expressed generally positive feelings. She often expressed relief, however, that they lived on opposite coasts since they ?got on each other's nerves. ANd ?[her daughter] needed her space to grow up.? Christina had few friends and intimate relationships other than with a man whom she perceived as weaker and to whom she responded with a mixture of affection and quiet contempt. Despite the apparent poverty of her relationships, she denied experiencing loneliness or the need for more connection.
Her previous treatment history consisted of family therapy during her daughter's drag treatment, and group psychotherapy in which she apparently alienated the group members by her blunt, calloused feedback. She was offended that they were apparently put off by her ?honesty.? Christina was also perceived by the group therapists as competing with them for control of the group.
Christina described her family in general, positive terms, despite specific memories of abuse and neglect during childhood and despite a current estrangement from her siblings. Her history of sexual abuse by her father and older sister was only acknowledged peripherally after several months of treatment and she remained resistant to exploring the current impact of the abuse on her life. She denied a traumatic reaction to the abuse, explaining that it was ?just one of those things that happened that you have to get over.?
Christina's engagement in therapy was generally limited to intellectualization. She would frequently ?spar? with the therapist who often found herself feeling inexpert and defensive. Attempts to focus on the therapeutic relationship would be resisted by the client through expressions of boredom or through superficial responses. After many frustrating months, therapy was mutually and unsuccessfully terminated through a referral to a sleep-disorders clinic.
Although much less research has been conducted about this pattern of attachment, it appears to be particularly pertinent to the experience of incest (Alexander et al., 1993). An understanding of the adult who is fearful/ unresolved with respect to attachment can benefit from an understanding of the disorganized child. As mentioned previously, the parent of the disorganized child tends to be frightened and/or frightening in his/her interactions with the child, presumably because the child becomes a trigger for memories of the parent's own history of traumatic abuse or loss (Main & Hesse, 1990). Consequently, the disorganized child is in the untenable position of needing to approach the very caretaker who is the source of the child's anxiety and fearfulness. The resulting approach/avoidance conflict renders the child unable successfully to develop a predictable coping strategy for interacting with the parent and, by extension, for learning how to regulate her own affect. In other words, the child is in a ?double bind? vis-୶is the parent (Spiegel, 1986) in which the experience of abuse, pain, fear, and humiliation by the parent is linked to the desired attention from the parent.
Just as apprehension, freezing, and a dazed demeanor characterize the disorganized child, dissociation is empirically more likely to be associated with fearful/unresolved attachment than other attachment categories (Anderson & Alexander, 1994). Furthermore, the unregulated affect of the disorganized child has its counterpart in an increased probability of borderline personality disorder in the fearful/unresolved adult (Alexander et al., 1993).
The individual who is preoccupied with respect to attachment also tends to be elevated on measures of borderline personality disorder and self-defeating behavior (Alexander et al., 1993) and may appear similarly confused and controlled by the memories of the trauma. However, differences in their histories of parenting and current functioning suggest a more successful therapy course for the individual who is preoccupied rather than fearful/unresolved. For example, individuals who are preoccupied had a strategy as resistant children to access, at least intermittently, their inconsistent parents by increasing their emotional display. Individuals who are fearful/unresolved, on the other hand, were caught in the dilemma as disorganized children of having no organized strategy to access their parents, because their very presence appeared to elicit a frightened or frightening response from the attachment figure (Main & Hesse, 1990). Consequently, as adults, they are more likely to see themselves as truly bad, responsible for the trauma, and inherently flawed (Main & Goldwyn, 1994) than are preoccupied individuals. The pain of fearful/unresolved adults is reflected in significantly more depression, distress, and poorer social adjustment than even preoccupied individuals (Alexander et al., 1993). Not unexpectedly, the adult classified as fearful/unresolved is also significantly more likely to exhibit extreme social avoidance, precisely because dependence upon others in childhood has been associated with trauma, abuse, and loss.
With her long history of betrayal and abuse by the very parent upon whom she was most dependent, the fearful/unresolved adult's commitment to therapy will be tenuous from the very beginning. She may cancel and/or reschedule appointments repeatedly. She may have had a high turnover of therapists. Her extreme interpersonal fearfulness makes her less likely to engage in group therapy, and if she does, less able to participate fully and to tolerate confrontation by other group members. As an adult, she may continue to exhibit the magical thinking and fearfulness of the abused small child who regards her parent as omniscient and omnipotent. Consequently, she may transferentially come to see the therapist as similarly endowed with malevolent power and influence.
In addition to the interpersonal avoidance, the client who is fearful/unresolved with respect to attachment will exhibit major problems with affect regulation. Just as she vacillated as a child between both approaching and avoiding her parent with terror, she will vacillate between approaching and avoiding her memories and emotions regarding her abuse and family history. Her approach/avoidance conflict is prototypical of that of the client with PTSD (Roth & Cohen, 1986). Because she has never developed any consistent strategy for dealing with painful affect, she may inadvertently disclose too much too fast with the result that she may bolt from the therapy relationship. She may see herself as too invisible and ineffectual to have an impact on others, may impulsively or explosively express her rage and terror, and then may feel vulnerable and attacked in response to others' reactions. In other words, she typically views feelings as inexplicable, powerful, and uncontrollable.
The overwhelming quality of the fearful/unresolved client's very real crises will undoubtedly leave the therapist feeling exhausted, ovemesponsible, and, occasionally, manipulated. However, several considerations can prove useful in working with this client. First is the recognition that her interpersonal fearfulness and avoidance are warranted given her past history and will only diminish slowly and gradually. Anger and even hatred are highly functional for the survivor classified as fearful/unresolved in that they insulate her from her attachment to her parent (and other attachment figures) and thereby dissipate her sense of vulnerability with someone who has betrayed her (Davenport, 1991). Therefore, the therapist needs to acknowledge to the client early and explicitly that the client's distrust and reticence are legitimate and justified while the therapeutic relationship is gradually becoming established. Second, a focus on empowerment and informed consent, including the client's choice to remember or not to remember, can help build upon the trust. Third, because the client is not going to be able to make use of the therapist easily and especially early in the therapy, the therapist needs to assess the client's other sources of support to help sustain her through the course of therapy. Unfortunately, she frequently is at a loss for other social supports, so exploring the use of structured, less intense support groups may prove useful.
From an attachment perspective, the primary emphasis in working with the client who is fearful/unresolved with respect to attachment needs to be on helping her gradually develop an awareness and strategy for regulating her affect. Consequently, the therapist needs to work very slowly and respectfully from the very beginning. For example, Dye & Roth (1991) discuss the danger of engaging in intense interactions about memories of abuse with a client who has a low tolerance for anxiety and who has few intimate relationships upon which she can rely during insight-oriented psychotherapy.
The client may initially require some interpersonal distance in order to modulate her negative affect. Therefore, a ?there and then? perspective is preferable until sufficient trust has been established in the relationship to allow a focus on the ?here and now.? Furthermore, she needs help in anticipating her responses to anxiety. By helping the client prepare for affective flooding, the therapist can give the client an anchor of predictability. In conclusion, titration of the client's affect, which then allows the client to feel more confident about relating to others, is the major emphasis in working with the client from this classification.
Sarah was a 39-year-old woman who was court-ordered to treatment as a result of her teenaged son's ongoing involvement in the court system for thefts, assaults, and drug-related offenses. At the time of the first contact, Sarah had ?fired? each of her two previous therapists after only an initial session and was late to her current intake interview. She was an angry, oppositional woman who hid behind mirrored sunglasses for many months. Due to her extreme social phobia, she would remain outside the building until the time for her session and would sit by the door during her session as though ready to flee. At the time she was first seen, Sarah was drinking excessively to handle her social phobia. It was many months into treatment before she was able to handle her anxiety sufficiently to attend Alcoholics Anonymous, six additional months before she could speak during an AA meeting, and a year before she could tolerate the relationship necessary to have a sponsor.
Disclosures around die sexual abuse by her father and others were accompanied by expressions of shame and rage in which she would either run from the therapy room or act-out after the disclosure. For example, she might kick the tires of the staff cars in the parking lot or refuse to enter the building for the next session. The therapeutic relationship required a constant balance between facilitating the development of increased therapeutic relatedness and holding Sarah increasingly responsible for acting appropriately (e.g., greeting the receptionist in a civil manner and no longer slamming doors or harassing coworkers by such acts as spilling coffee on a freshly typed report). This constant attention to boundaries within the therapeutic relationship by confronting Sarah's behavior produced numerous small therapeutic ruptures which could then be resolved through a supportive therapeutic relationship. Thus, the therapeutic alliance was constantly being renegotiated with the goal of helping Sarah contain and regulate her own affect and behavior.
Termination occurred after four years when the therapist moved to another city. Although it led to some acting-out (Sarah stole the therapist's ?For Sale? sign from her front yard), Sarah made further gains with another therapist. Sarah is no longer in therapy and currently has a well-developed support system through her AA community where she has functioned as a sponsor and in other responsible positions. However, she continues to regard the original therapist as a secure base and makes brief telephone contact with the therapist when her stress is high. These brief contacts allow for support and nurturance and provide Sarah with a marker for the vast amount of change she has accomplished.
As this article has demonstrated, attachment theory is pertinent to the wide array of interpersonal dynamics and problems of affect regulation exhibited in survivors of incest. The centrality of the parent-child relationship which mediates the experience of incest is made manifest in the expectations and self-fulfilling prophecies of later intimate relationships, including the therapy relationship. By appreciating the importance and nuances of this early attachment relationship, the therapist is in a better position to avoid reinforcing the client's existing internal working model. Since the goal of all therapy is secure attachment, the therapist works with the client's internal working model of herself, the therapist, and other important people in her life. The therapist helps the client gain access to both positive and negative feelings and to a more complex and coherent understanding of relationships. The client thus develops a more successful strategy of regulating painful affect and achieving secure and rewarding attachment relationships.
AINSWORTH, M.D.S. (1989). Attachments beyond infancy. American Psychologist, 44, 709?716. Ovid Full Text Library Holdings [Context Link]
ALEXANDER, P. C. (1992). Application of attachment theory to the study of sexual abuse. Journal of Consulting and Clinical Psychology, 60, 185?195. [Context Link]
ALEXANDER, P. C. (1993). The differential effects of abuse characteristics and attachment in the prediction of longterm effects of sexual abuse. Journal of Interpersonal Violence, 8, 346?362. Library Holdings [Context Link]
ALEXANDER, P. C, ANDERSON, C, SCHAEFFER, C. M., BRAND, B., ZACHARY, B. & KRETZ, L. (1993). Attachment as a mediator of longterm effects in survivors of incest. Submitted for review.
ANDERSON, C. L. & ALEXANDER, P. C. (1994). The relationship between attachment and dissociation in adult survivors of incest. Submitted for review. [Context Link]
BOWLBY, J. (1969/1982). Attachment and loss: Vol. 1: Attachment. New York: Basic. [Context Link]
BOWLBY, J. (1988). A secure base. New York: Basic. [Context Link]
BRENNAN, K. A. & SHAVER, P. R. (1991). Dimensions of adult attachment and the dynamics of romantic relationships. Unpublished manuscript. [Context Link]
BRETHERTON, I. (1985). Attachment theory, retrospect and prospect. In I. Bretherton and E. Waters (Eds.), Growing points in attachment theory and research (pp. 3?38). Monographs of the Society for Research in Child Development, 49 (6, Serial No. 209).
BRIERE, J. (1989). Therapy for adults molested as children: Beyond survival. New York: Springer. [Context Link]
BRIERE, J. & RUNTZ, M. (1990). Differential adult symptomatology associated with three types of child abuse histories. Child Abuse & Neglect, 14, 357?364. Bibliographic Links Library Holdings [Context Link]
CARLSON, V., CICCHETTI, D., BARNETT, D. & BRAUNWALD, K. (1989). Disorganized/disoriented attachment relationships in maltreated infants. Developmental Psychology, 25, 525?531. Ovid Full Text Bibliographic Links Library Holdings [Context Link]
CECCHIN, G. (1979). Hypothesizing, circularity, and neutrality revisited: An invitation to curiosity. Family Process, 26, 405?413. Library Holdings
COHN, D. A., SILVER, D. H., COWAN, C. P., COWAN, P. A. & PEARSON, J. (1992). Working models of childhood attachment and couple relationships. Journal of Family Issues, 13, 432?449. Library Holdings
COLLINS, N. L. & READ, S. J. (1990). Adult attachment, working models, and relationship quality in dating couples. Journal of Personality and Social Psychology, 58, 644?663. [Context Link]
COURTOIS, C. (1988). Healing the incest wound. New York: Norton. [Context Link]
CRITTENDEN, P. M., PARTRIDGE, M. F. & CLAUSSEN, A. H. (1991). Family patterns of relationship in normative and dysfunctional families. Developmental and Psychopathology, 3, 491?512. [Context Link]
DAVENPORT, D. S. (1991). The functions of anger and forgiveness: Guidelines for psychotherapy with victims. Psychotherapy, 28, 140?144. Ovid Full Text Library Holdings [Context Link]
DOLAN, R. T., ARNKOFF, D. B. & GLASS, C. R. (1993). Client attachment style and the psychotherapist's interpersonal stance. Psychotherapy, 30, 408?412. Ovid Full Text Library Holdings [Context Link]
DOZIER, M. & KOBAK, R. R. (1992). Psychophysiology in attachment interviews: Converging evidence for deactivating strategies. Child Development, 63, 1473?1480. Bibliographic Links Library Holdings [Context Link]
DYE, E. & ROTH, S. (1991). Psychotherapy with Vietnam veterans and rape and incest survivors. Psychotherapy, 28, 103?120. Ovid Full Text Library Holdings [Context Link]
EDWARDS, J. J. & ALEXANDER, P. C. (1992). The contribution of family background to the long-term adjustment of women sexually abused as children. Journal of Interpersonal Violence, 7, 306?320. Library Holdings [Context Link]
EGELAND, B. & SROUFE, L. A. (1981). Attachment and early maltreatment. Child Development, 59, 44?52. Library Holdings [Context Link]
FEENEY, J. A. & NOLLER, P. (1990). Attachment style as a predictor of adult romantic relationships. Journal of Personality and Social Psychology, 58, 281?291. [Context Link]
FINKELHOR, D. (1984). Four preconditions: A model. In D. Finkelhor, Child sexual abuse: New theory and research (pp. 53?68). New York: Free Press. [Context Link]
FOLLETTE, V. M., ALEXANDER, P. C. & FOLLETTE, W. C. (1991). Individual predictors of outcome in group treatment for incest survivors. Journal of Consulting and Clinical Psychology, 59, 150?155. [Context Link]
FRIEDRICH, W. N., BEILKE, R. & URQUIZA, A. J. (1987). Children from sexually abusive families: A behavioral comparison. Journal of Interpersonal Violence, 2, 391?402. Library Holdings [Context Link]
GIL, E. (1988). Treatment of adult survivors of childhood abuse. Walnut Creek, CA: Launch. [Context Link]
HAAKAN, J. & SCHLAPS, A. (1991). Incest resolution therapy and the objectification of sexual abuse. Psychotherapy, 28, 39?47. [Context Link]
HAFT, W. L. & SLADE, A. (1989). Affect attunement and maternal attachment: A pilot study. Infant Mental Health Journal, 10, 157?172. Library Holdings [Context Link]
HARTER, S., ALEXANDER, P. C & NEIMEYER, R. A. (1988). Long-term effects of incestuous child abuse in college women: Social adjustment, social cognition, and family characteristics. Journal of Consulting and Clinical Psychology, 56, 5?8. [Context Link]
HAZAN, C. & SHAVER, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52, 511?624. [Context Link]
HERMAN, J. (1992). Trauma and recovery. New York: Basic. [Context Link]
IZARD, C. & KOBAK, R. (1991). Emotion system functioning and emotion regulation. In J. Garber and K. Dodge (Eds.), The development of affect regulation (pp. 303?321). Cambridge: Cambridge University Press. [Context Link]
KOBAK, R. & SCEERY, A. (1988). Attachment in late adolescence: Working models, affect regulation, and representations of self and others. Child Development, 59, 396?399. [Context Link]
LUBORSKY, L., CRITS-CRISTOPH, P., MlNTZ, I. & AUERBACH, A. (1988). Who will benefit from psychotherapy? Predicting therapeutic outcomes. New York: Basic. [Context Link]
MAIN, M. (1990). Cross-cultural studies of attachment organization: Recent studies, changing methodologies, and the concept of conditional strategies. Human Development, 33, 48?61. Library Holdings [Context Link]
MAIN, M. & CASSIDY, J. (1988). Categories of response to reunion with the parent at age 6: Predictable from infant attachment classifications and stable over a one-month period. Developmental Psychology, 24, 415?426. Ovid Full Text Bibliographic Links Library Holdings [Context Link]
MAIN, M. & GOLDWYN, R. (1984). Predicting rejection of her infant from mother's representation of her own experience: Implications for the abused-abusing intergenerational cycle. Child Abuse & Neglect, 8, 203?217. Library Holdings [Context Link]
MAIN, M. & GOLDWYN, R. (1994). Adult attachment scoring and classification systems. Unpublished manuscript. [Context Link]
MAIN, M. & HESSE, E. (1990). Parents' unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/or frightening parental behavior die Unking mechanism? In M. Greenberg, D. Cicchetti, and M. Cummings (Eds.), Attachment in the preschool years (pp. 161?182). Chicago: University of Chicago Press. [Context Link]
MAIN,
M. & SOLOMON, J. (1986). Discovery of an insecure-disorganized/
MAIN, M., KAPLAN, N. & CASSIDY, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. In I. Bremerton and E. Waters (Eds.), Growing points of attachment theory and research: Monographs of the Society for Research in Child Development, 50(1?2), Serial No. 209, pp. 66?104. [Context Link]
MCMILLEN, J. C. (1992). Attachment theory and clinical social work. Clinical Social Work Journal, 20, 205?218. Library Holdings [Context Link]
MIKULNCER, M. & NACHSHON, O. (1991). Attachment styles and patterns of self-disclosure. Journal of Personality and Social Psychology, 61, 321?331. [Context Link]
MIKULINCER, M., FLORIAN, V. & TOLMACZ, R. (1990). Attachment styles and fear of personal death: A case study of affect regulation. Journal of Personality and Social Psychology, 58, 273?280. [Context Link]
OLIO, K. A. & CORNELL, W. F. (1993). The therapeutic relationship as the foundation for treatment with adult survivors of sexual abuse. Psychotherapy, 30, 512?523. Ovid Full Text Library Holdings [Context Link]
PETERS, S. D. (1988). Child sexual abuse and later psychological problems. In G. E. Wyatt and G. J. Powell (Eds.), Lasting effects of child sexual abuse (pp. 101?117). New-bury Park, CA: Sage. [Context Link]
PISTOLE, M. C. (1989). Attachment in adult romantic relationships: Style of conflict resolution and relationship satisfaction. Journal of Social and Personal Relationships, 6, 505?510. [Context Link]
ROTH, S. & COHEN, L. J. (1986). Approach, avoidance, and coping with stress. American Psychologist, 41, 813?819. Ovid Full Text Library Holdings [Context Link]
SABLE, P. (1992). Attachment theory: Application to clinical practice with adults. Clinical Social Work Journal, 20, 271?283. Library Holdings [Context Link]
SCHNEIDER-ROSEN, K., BRAUNWALD, K. G., CARLSON, V. & CICCHETTI, D. (1985). Current perspectives in attachment theory: Illustration from the study of maltreated infants. In I. Bremerton and E. Waters (Eds.), Growing points in attachment theory and research: Monographs of the Society for Research in Child Development, 50(1?2), Serial No. 209, pp. 194?210. [Context Link]
SILVER, R. L., BOON, C & STONES, M. H. (1983). Searching for meaning in misfortune: Making sense of incest. Journal of Social Issues, 39, 81?102. [Context Link]
SPIEGEL, D. (1986). Dissociation, double binds, and posttraumatic stress in multiple personality disorder. In B. Braun (Ed.), Treatment of multiple personality disorder (pp. 63?77). Washington, DC: American Psychiatric Press. [Context Link]
SROUFE, L. A. (1988). The role of infant-caregiver attachment in development. In J. Belsky and T. Nezworski (Eds.), Clinical implications of attachment (pp. 18?38). Hillsdale, NJ: Erlbaum. [Context Link]
TROY, M. & SROUFE, L. A. (1987). Victimization among preschoolers: Role of attachment relationship history. Journal of the American Academy of Child Psychiatry, 26, 166?172. [Context Link]
WEISS, R. S. (1991). The attachment bond in childhood and adulthood. In C. M. Parkes, J. Stevenson-Hinde, and P. Marris (Eds.), Attachment across the life cycle (pp. 66?76). New York: Tavistock/Routledge. [Context Link]
WEST, M., SHELDON, A. & REIFFER, L. (1989). Attachment theory and brief psychotherapy: Applying current research to clinical interventions. Canadian Journal of Psychiatry, 34, 369?375. Library Holdings [Context Link]
WINNICOTT, D. W. (1965). The maturational processes and the facilitating environment. London: Hogarth. [Context Link]
ZEANAH, C. H. & ZEANAH, P. D. (1989). Intergenerational transmission of maltreatment: Insights from attachment theory and research. Psychiatry, 52, 177?196. [Context Link]
Accession Number: 00011673-199403140-00011