PRACTICE MANAGEMENT:
- CEU Tracking
- ATD Updated: it was suggested that a place for listing client medications be added to the form & this is now completed. Great idea Jesse!
DIDACTIC: ACTIVATING THE ATTACHMENT SYSTEM PT. 2
-
-
- Diagnosis & Treatment of Any Associated Mental Disorder
-
Intervention #4: Using Symptoms as Motivators
Understand that regardless of an individual’s prior history, the actual decision to come for therapy often occurs at a time when defenses have broken down in the here and now. Trauma theorists refer to the “disguised presentations” that bring individuals into treatment, especially those with histories of childhood abuse. Judith Herman wrote:
- They come for help because of their many symptoms or because of difficulty with relationships, problems in intimacy . . . and repeated victimization. All too commonly, neither patient nor therapist recognizes the link between the presenting problem and the history of chronic trauma.
Some other very common presentations for clients who are avoidant of attachment often seek therapy because of loneliness & depression. Understand this, know this is the case, or you will mislabel what is in front of you as Major Depression or Generalized Anxiety. These struggles are accompanied by symptoms of depression, isolation & anxiety. And why would they not be? Life was not meant to be experienced alone.
For the therapist, such crisis in cause/opportunity for deeper exploration & perhaps healing. For the client, the focus is the symptoms going away. And here is our chance.
- Make the Symptoms Meaningful: Early in treatment, it is important to help the client make a motivational shift from simple symptom relief to one in which therapy starts to feel important on a deeper level. A shift in which the person begins to experience a more meaningful connection to the process. If the individual’s motivation for therapy stays at the level of simple symptoms relief, he may become rapidly disillusioned with the process, terminating treatment long before it is complete. It is common that symptoms abate relatively quickly (for a brief time) following the initiation of therapy. As such, the client believes they are better. This relief may start as quickly as placing the call to make the first session. Why does this occur? There is a direct symptomatic benefit to experiencing an increase in social support. Simply by bringing the counselor in, research shows there will be an improvement. Specifically, support from a perceived authority figure has shown to be helpful.
- Clarifying Motivation: Individuals with attachment histories have a checkered past of trying to get help and stopping (help can take various forms and is not limited to formal counseling). The client was motivated temporarily by times of decompensation. Here we must be curious. The following are the types of questions we should ask:
- What did you find to be the most difficult about therapy/the last time you had this problem?
- Why would this time be different?
- If they have not been in therapy before: Why enter it now?
- Why would therapy help now?
When the client responds in global, impressionistic, stereotypic ways with goals like, “I don’t want to be so negative all the time,” without any clear justification, it is helpful to take the opportunity to gently challenge the client as to why. What is in it for them to “stop being so negative?” What might they gain, and what might they lose?
- Connecting Symptoms to Attachment: Connecting symptoms to attachment refers to the idea that the therapist helps the client explicitly connect symptoms to psychologically meaningful reasons for treatment. How to do this? There are a number of options, but the basic theme is the same, going back to the relationship. One tactic is to have the client sharing about current symptoms in life and then have them recall the earliest time in their life they can remember feeling in a similar way. From there, the therapist explores their connections and relationships at that time in life. Another option would be to explore who the client allows to help them currently with their struggles. Be creative, but take things back to the relationship. Thus, the individual who allows himself to make the shift from viewing the problems as “depression & loneliness” to that of “self-isolation” or to that of “keeping people at arms’ length” is far more likely to find therapy meaningful. One warning, especially to the beginning therapist, none of these interventions should take the form of pontificating possible theories to the client. These individuals will experience this as artificial and contrived. You must work with what the client is giving you, do not over-reach or you will lose them.
- All of the questions follows this basic path:
- What is the effect of (symptom) on (relevant attachment theme)?
- What is the effect of (relevant attachment theme) on (symptom)?
- In practic, this may look something like, “How has depression affected your relationship with Paul?” Or “How has your engagement to Paul effected your depression?” Or perhaps “How did the performance anxiety affect your decision to have children?” Or “How did fear of having children effect your performance anxiety?”
- The questions themselves are not as important as the therapist repeatedly demonstrating assigning meaning to the symptoms. The client will often respond that outside of therapy something happened and they heard the therapist’s line of questioning and it caused them to look in depth at such matters. It is a position which is not assigned but caught.
- All of the questions follows this basic path:
- Dismissing Disillusionment: Know that the very process of becoming symptomatic is in, and of itself, often a kind of injury to the attachment avoidant client. Theorists refer to this as “dismissing disillusionment.” As the term suggests, when they become symptomatic, clients who are avoidant (dismissing) of attachment tend to experience a profound sense of feeling disillusioned. Such individuals can cope with emotional ups and downs in life provided these issues do not touch on attachment related hurts. A therapist can ally with the distress of the disillusionment. They can do this by allying with the individual’s motivation to understand why she would be feeling much worse than before. Given the tendency toward strength and self-reliance, such individuals feel considerable disappointment in themselves for becoming symptomatic. There is a sense of personal failure and humiliation or anger at themselves for “falling apart” and a desire to figure out how to protect themselves from falling apart in the future. The therapist aligns with this strong motivation. (example: “This week has really been tough for you. I’d like to see if we can figure out how to keep you from getting knocked off your feet like that again. An important part of that will be understanding what was going internally for you.”)
- Focusing on Themes of Vulnerability: The therapist should be listening for the meanings attached to symptoms. Understand we are all, even the avoidant, trying to make sense of life. Often times, their symptoms have very curious meanings. The meanings and symptoms can be brought back to vulnerability. Know this, the word “vulnerable” is offensive to the attachment avoidant. It is a disease, a weakness. When individuals have experienced histories of trauma, particularly when suffering comes at the hands of those trusted most, there is a painful awareness of the price to be paid for excessive vulnerability. Vulnerability can mean weakness and may be frightening or dangerous. Avoidance of attachment is the pursuit of invulnerability, the pursuit of an illusion that offers strength, reassurance, and a promise of safety. Part of the reason the client feels so profoundly disillusioned when she becomes symptomatic is that she has become painfully aware, again, of the harsh reality of her human weakness and all the dangers that go along with it. An important component of treatment is in helping the client gain greater acceptance of her vulnerabilities integrating them into her overall sense of self, so that they can eventually feel less dangerous and frightening.
- For example, consider the person who declares “weakness” as his word to describe the meaning of fear to him. This word can be contrasted with the individual’s more usual backdrop of “strength.” The therapist and client can then reflect on this weakness. The therapist enquires about it’s history in the person’s life. “When was the first time you showed anyone your weak side?” “On the rare occasions that it occurred, how did your parents deal with such weakness on your part?” “How have you reacted to such weakness in others?” “How is it others got the chance to be so weak and you had to be so strong?” Again, the questions & their answers are not nearly as important as process of self-reflection. Recognizing feelings around having become symptomatic and then connecting them to other experiences of vulnerability helps the client integrate a far more textured and realistic view of self, a view in which stories of strength and weakness, independence and fear, can come to coexist.
Review:
- Take note of initial buy-in that has been prompted by the presence of symptoms.
- Clarify motivation for therapy:
- Ask the client to reflect on her response for taking on therapy given that it raises uncomfortable, difficult feelings.
- Help the individual make connections between symptoms and attachment-related issues (to further strengthen motivation for therapy).
- Notice client disillusionment (over having become symptomatic).
- Ally with the individual’s motivation to understand why she would be feeling so much worse than before.
- Be curious about and examine the meaning of symptoms that are suggestive of themes of vulnerability.
Intervention #5: Listening for, Noticing & Using Ambivalence
Despite great efforts not to feel difficult emotions, some things are hard to avoid indefinitely. The very nature of trauma and attachment related struggles is that they are bound to be triggered at some point. In describing the process of deactivation (which we defined previously), Bowlby noted that the exclusion of significant information may be less than complete, and that there are times when “fragments of information defensively excluded seep through.” Life changes, such as actual or perceived losses, medical illnesses, family crisis, and developmental shifts (becoming a parent, getting married, etc) can trigger such struggles.
When such triggers occur, the attachment avoidant individual may go back to relying on previous coping mechanisms such as minimization and denial. However, the nature of trauma is that it is not so easily avoided. The desire to discuss aspects of previous traumatic experiences and the reluctance to do so out of fear is the recipe for ambivalence. Such naturally occurring ambivalence can serve as windows of opportunity in therapy.
A client will make reference to things that are triggered for them but may also note “I am over that.” The therapist can ask about why, if this matter is irrelevant or dealt with, it was brought up. The client may likely say they are unsure. The therapist can catalog this for later. Either the subject will be brought up again by the client at some point or another similar topic is brought up and the therapist can ask a question connecting the two events such as “Is this similar to how you felt when . . .?”
Therapist Feelings When Responding to Ambivalence: The others side of client ambivalence is the piece the therapist brings to the table, that is, the extent to which the clinician turns the attention toward trauma related material, and focuses on it, when it naturally arises in the treatment process. The decision of whether or not to pursue is often a difficult one. Such clients drop “fragments” (Bowlby) in places throughout their conversations with the therapist. The therapist is trying to decide which of these references to focus on, encouraging greater clarification and embellishment. In a sense, the therapist is left holding the ambivalence that the client cannot tolerate holding himself. The “pull” is for the therapist to resolve this in the simplest and most comfortable manner by going along with what the individual is most obviously asking for. When the client minimizes the magnitude of the trauma, there is pressure on the therapist to do so as well. When the individual conveys dismissal of the therapist’s questions regarding trauma, the therapist may naturally accommodate and adjust her questioning.
Clients who are avoidant of attachment often respond to questioning about trauma-related feelings by rejecting them outright, minimizing therapist observations, or using defenses such as intellectualization to dampen the intensity of the therapist’s comments. In response, the therapist may react to such rejection or minimization with a variety of normal emotions (frustration, irritation, hurt, disappointment) depending on the clinician’s personal history and attachment pattern. The therapist may, over time, begin to collude with the client, avoiding talking about trauma related material or “watering it down.”
The therapist is challenged to make active attempts to turn attention toward trauma-related material, to listen for it, notice it, ask about it, and to facilitate rather than avoid such painful topics. If not, the risk is that of replicated the rejecting response of the parent who reacts to the child’s abuse revelations by discounting or minimizing their importance or of replicating the weak and incapable parent who cannot tolerate her child telling her about what is really going on without squelching the information, failing to react, over-reacting, or falling apart emotionally. A therapist must become comfortable with hearing the pain of the client, noting that even subtle reluctance and anxiety on the therapist’s part are often communicated to the individual, and that the client often withholds telling the full story out of fear the therapist might not be able to handle it. We are to be able to “bear witness” of the client’s pain and must deal with any hesitation on our part.
Don’t:
- Collude with general reluctance to address traumatic experiences.
Do:
- Listen for and notice moments of client ambivalence in relation to trauma & attachment experiences.
- Consider ambivalence to be a therapeutic opportunity.
- Take the opportunity to ask the client to reflect on and make meaning of traumatic experiences.
- Notice times you get pulled into colluding with avoidance.
- Think to yourself about what those times might say about you.
Intervention #6: Asking Questions Around Themes of Caregiving & Protection
By definition, clients who are avoidance of attachment are reluctant to turn their attention toward memories, thoughts, and feelings that remind them of early relationships. This makes it a challenge for them to engage in therapy because virtually all modalities of therapy invite the person to take part in the act of self-reflection on problematic relationships, and the analysis of situation, thoughts, and feelings marked by interpersonal conflict. We must look at the relational map, and clients who avoid doing so are unlikely to find therapy helpful.
While these individuals are often avoidant of looking at their own caregivers (parents) they are often willing to engage in discussion regarding the protection of others, such as romantic partners, their children, or even future imagined children. Now, it is important to note that avoidant attachment in individuals is a strong predictor of insecure attachment with children. As such, their desired relationship with others may not be like their actual relationship with those they care about. In therapy, the act of thinking about protecting others is one in which such clients are willing to engage and do so much more readily than the act of thinking about their own history of failed protection.
It is not uncommon for these clients to bring up caregiving in other contexts as well. These may include workplace and friendship experiences in which they figure as the one others came to in times of need or the one who protected a colleague: the benevolent team leader, the one who stuck out his neck to protect a friend, or the one who gave money to the secretary whose child really needed it. There may be a certain bravado and self-indulgence in this helping, needing to be a rescuer or savior. The stories may not be that accurate. But that is secondary in importance. What is of use in treatment is the knowledge that such stories are in the client’s mind. The individual who is powerfully engaged by his role as protector, through his actions and words, is trying to work something through, to somehow complete the protection that never came to pass in his own life, and in the process, he is attempting to undo the pain of his own history.
An example of utilizing this would be a man who has strongly identified with one of his children. The client frequently brings up the child and concerns about him. The therapist notices these protection stories and invites reflection on the meaning of protection for the person’s life. Most importantly, it is critical to help the individual make a connection between protection outward and experience inward. Once reflecting on caregiving has been initiated and discourse on the act of protecting others has been opened, the client can start to make connections to his personal story. There will be some softening to the idea of looking inward. The therapist can then ask about the similarities or differences between the client’s experiences of protecting others and his experiences around being protected (or not) as a child. It is important to note that the parallels between protecting others and the client’s personal history of failed protection are most useful when drawn in emotional terms. For example, once the client above is able to speak about his child being “heartbroken” and how he desperately wished he could fix that for him, he might be able to admit more freely to times in his own childhood when he wanted, more than anything else, to make that heartbroken feeling go away forever.
Review:
- Pay attention to themes of caregiving and protecting others in the client’s life.
- Invite the client to reflect on the meaning around particular acts of protecting others.
- Help the client look at similarities/differences between protecting others and personal experiences around being protected (or not) as a child.
Source: Muller, R. T. (2010). Trauma and the avoidant client: attachment-based strategies for healing. New York: W.W. Norton & Co.
MCO - CEU Tracker
Team Meeting Discussion Video
Topic: MCOTeam Meeting
Date : Feb 21, 2018 9:57 AM Mountain Time (US and Canada)
https://zoom.us/recording/play/Z72J8oIPgwuIOCCziclbQR-6nwfSGtIQaA0Y4DXgkJOi7o_Ukp-ysRP_I07ZaSla