10. Attachment - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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I Don't… You Don't… It Don't Matter, Depression and Anxiety in Couples and Couple Therapy
Chapter 10: ATTACHMENT


The therapist may work from any of many theoretical orientations and use different strategies, techniques, or interventions.  The therapist might consider and familiar how the nine steps of emotionally focused couple therapy (EFT) (Dessaulles et al, 2003, page 348) address depression/anxiety and marital issues.  It may resonate with many theoretical perspectives and therapeutic strategies.  "EFT is carried out in nine steps:

(1) delineate the conflict issues between the partners,

(2) identify the negative interaction cycle,

(3) access unacknowledged feelings underlying interactional positions,

(4) reframe the problem(s) in terms of underlying feelings,

(5) promote identification with disowned needs and aspects of self,

(6) promote acceptance by each partner of the other partner's experience,

(7) facilitate the expression of needs and wants to restructure the interaction based on the new understandings,

(8) establish the emergence of new solutions (cycles), and

(9) consolidate new positions" ( Johnson & Denton, 2002, p. 230).

Naaman, et al., (2005, page 63-64) described the nine steps of EFT in three phases.  The first phase of Cycle De-escalation (steps 1-4) includes developing rapport between therapist and clients.  

(1) delineate the conflict issues between the partners,

(2) identify the negative interaction cycle,

(3) access unacknowledged feelings underlying interactional positions,

(4) reframe the problem(s) in terms of underlying feelings,

Stating and validating the depression/anxiety or emotional injury of each partner serves powerfully to create immediate alliance.  Core issues are revealed and explained in terms of attachment (mattering, anxiety, and depression for example).  Therapy explains how their negative interactional cycle plays out in insecurity and relational distress.  Unexpressed feelings are brought forward and reframed.  This often focuses on transactional diagnoses, emotional interplay, and/or symbolic meanings.  They often reflect variations and degrees of anxiety and/or depression.  Whatever was originally identified as the presenting problem is reframed in terms of the interactional cycle, underlying emotions, and attachment needs.  The second therapeutic phase (steps 5-7) of Changing Interactional Positions identifies previously disowned needs and aspects of self and integrates them into relationship interactions.  

(5) promote identification with disowned needs and aspects of self,

(6) promote acceptance by each partner of the other partner's experience,

(7) facilitate the expression of needs and wants to restructure the interaction based on the new understandings,

Once discounted, ignored, or missed, active integration of such needs and self-aspects communicates that they (and the person) matter.  As a partner accepts the other partner's experience as real and relevant- mattering, they start to learn flexible more responsive interactions. Expression of attachment needs and wants are facilitated, which mitigate anxiety and depression.  This facilitates security and emotional engagement.  The third therapeutic phase of Consolidation and Integration looks and deals with previous relationship problems using new perspectives and strategies developed through therapy, and considers the couple's new positions and healthier cycles of attachment behavior.

(8) establish the emergence of new solutions (cycles), and

(9) consolidate new positions" ( Johnson & Denton, 2002, p. 230).

Emotional and subsequent behavior comes from a complexity of intrapsychic, interpersonal, and experiential factors at many different levels and from many different historical contexts.  There are arguably many "third" variables that cause depression/anxiety and relationship problems as well.  Such additional variables correlate with depression/anxiety and/or relationship discord.  Heene et al. (2005, page 414-15) examined three such variables: conflict communication during marital difficulties, attributions, and attachment style. "…there is substantial evidence on the associations between conflict communication, attributions, and attachment on the one hand, and depression and marital distress on the other."  Conflict communication, attributions, or attachment "may moderate the association between depressive symptoms and marital satisfaction, with specific characteristics probably related to distinct outcomes such as levels of marital satisfaction (page 416).  The manner that partners communicate, along with specific attributions, and/or expectations and experiences of relationship attachment may buffer or intensify the negative effects of depressive symptoms on relationships.  Attributions were discussed previously in this paper.  EFT is founded in attachment theory, which is why its approach may resonate with many therapists.  The adult romantic relationship serves the same basic attachment function as the parent-child.  Securely attached individuals tend to feel more competent in relationships than do insecure people.  "From an attachment perspective, depressives' problematic adult relationships are associated with early negative experiences with a primary caregiver, in which they learn to expect future attachment figures to respond in a similarly rejecting or inconsistent way" (Heene et al., 2003, page 135).  People with problematic attachment histories may interpret ambiguous occurrences from their negative working models.  These perceptions subsequently create stress and depression.  People with problematic attachment experiences often hold attitudes that are dysfunctional.  These dysfunctional attitudes, especially regarding performance influence the connection between attachment insecurity and depression.

Avoidance of his or her partner's depression and co-existing feelings of helplessness to deal with the depressive circumstances increases depressive symptoms in the otherwise healthier partner.  Moreover, it is likely that the partner's depression contribute to avoidant behavior.  Depressive symptoms and an avoidant coping strategy may be mutually reinforcing.  Avoidant coping strategy by the partner of the depressed individual hinders the individual and the couple in dealing with stress.  Avoidant coping strategy also adversely affects relationship functioning.  "Avoidance implies that difficult emotions (such as the partner's depression) and practical problems in the marriage are not addressed, confronted, and constructively managed" (Spangenberg & Theron, 1999, page 259).  Anxious avoidant attached children have minimal confidence that caregivers will respond positively.  They expect to be rejected.  As adults, they may become compulsively self-reliant and try to live by themselves without attachments.  They stay detached.  They don't trust that others will meet their needs.  "Kohut's 'contact-shunning' personalities… tend to avoid social interaction, frequently use projection as a defence and become isolated out of their fear of engulfment.  Hill (1996) suggests that this fear of engulfment is understood to be the fear of being emotionally overwhelmed should the person allow his or her emotions to be experienced.  He gives the example of working with an avoidantly attached adolescent who vehemently announced, "I'm not going to cry; because if I did, I would never stop (Hill, 1996, p. 70)" (Hill, 2009, page 6-7).  With the habitual defense mechanism to suppress disturbing emotions, avoidant adults are more likely to stay detached in their relationships whether or not they experience relationship distress.  Avoidant individuals are not comfortable with emotional closeness, and as a result will shut down and pull away if partners are rejecting.  Denial of a need for love and intimacy fears harm relationships.  "Horowitz, Rosenberg, and Bartholomew (1993)… did report that individuals displaying problems with coldness and vindictiveness received fewer positive gains from brief dynamic psychotherapy.  Since a propensity towards interpersonal 'coldness' is characteristic of fearful attachment, it would be expected that fearful individuals would be less successful in psychotherapy" (Reis and Grenyer, 2004, page 415).  Avoidant and dismissive attachment have similarities.  Interpersonal behaviors associated with dismissing attachment may create a self-confirming process.  Individuals who are dismissive of partners exhibit low levels of warmth, caregiving, and emotional responsiveness in close relationships.

Braydon and Audrey behave consistently based on negative assumptions of being dismissed, minimized, or ignored.  And fairly consistently got confirmation of their negative anticipations in their partner's responses.  When Audrey wants to take vacation time to visit with her parents, she expects that Braydon will be resistant to the idea.  Instead of presenting the idea reasonably along with her motivations, she puts it out aggressively.  Anticipating dismissal, she puts it to him as an ultimatum in a hostile and condescending tone.  "You got to visit your parents all the time.  I'm tired of going there.  Your brother is always going to be their favorite, no matter how many times we visit.  Give it up. I'm sick of going there.  Ain't no way, I'm going there again.  It's my turn to visit my parents.  You hear me!?"   Braydon gave Audrey a cold look, "Sure, I hear you.  Now, you hear me.  So, you want to visit your mommy?  We went there last summer."  Because Audrey buttressed her case with several issues in anticipation of Braydon's lack of responsiveness, she inadvertently gave him a whole set of avenues to avoid responding to her key issue- her desire to visit her parents.  Drawing Audrey into an argument about how often they have visited her parents, when, how she may be negative at his parent's house, or who's the boss and so forth, become ways to avoid not just her desire but also the underlying disconnection between them.  Audrey gets dismissed easily.  However, she had preemptively dismissed Braydon's desire for connection or intimacy with his parents (whatever the issues are about his brother) and any other desire or need when she proclaimed, the "Ain't no way…" ultimatum.  Both partners get confirmation of the others' lack of warmth and caregiving.  

Neither partner has really started this dismissal/avoidance process in the current argument.  They are working off numerous negative historical experiences and are merely getting further proof of one another's emotionally unavailability.  This battle becomes one more confirmation of how one cannot get care or love from the other.  This may be confirmation of fears of being unlovable.  The interaction activates dysfunctional attitudes and behaviors about needs for autonomy as well.  Such interactions maintain the couple's negative process.  "Verification from significant relationships that negative working models and/or dysfunctional attitudes are true may help to maintain depression.  This finding appears to reflect the interplay of intrapsychic vulnerabilities and real-world relationships" (Whiffen, 2001, page 587).  On the other hand, securely attached individuals tend to feel positively about themselves and others even when having difficult times in the relationship.  This helps them not be as depressed and predict better functioning dealing with relationship problems.  The same characteristics predict ease and success in couple therapy.  While there is anticipation of negative outcomes in more stable individuals, there is also more hope that there will be better outcomes.  Hopeful partners tend to be less aggressive, less negatively sensitive, and more open to positive responses from the other.  This changes their emotional and verbal communications, which in turn makes it less likely that they will elicit negative responses.  The therapist assesses these communication dynamics to see how embedded negative anticipation may be.  Simple communication training may not suffice, if one or both partners are highly fragile due to attachment vulnerabilities.

Poor attachment can manifest in different ways.  For example, "insecurely attached individuals believe that they must strive for high levels of achievement and autonomy to feel good about themselves, a belief that puts them at risk for depression" (Wiffen et al., 2001, page 579).  This may mean trying to be a perfect nurturing and supportive partner yet simultaneously highly independent.  They may fear that failure to achieve such behavior would result in rejection and abandonment.  Hill (2009) discussed the anxious resistant attachment pattern, when a child feels uncertain whether his or her attachment figure will be available and responsive.  The inconsistency of availability and absence causes anxiety and despair.  The child has persistent separation anxiety and becomes clingy and insecure about venturing out to explore.  "Adults who have experienced this type of attachment style often become compulsive caregivers.  They never felt sufficiently cared for, but were not disappointed enough to give up trying… Such persons tend to cling in relationships, feel helpless or powerless, fear abandonment and are more susceptible to protective identification" (Hill, 2009, page 6-7).  "…depression clearly is associated with negative working models of self and others.  Specifically, depression is associated with the beliefs that one is unlovable and that attachment figures will be rejecting.  As proposed by others, fearful attachment may be a stable, individual difference variable that acts as a vulnerability factor in depression (e.g., Ingram et al., 1998; Roberts et al., 1996).  Cognitive processes may be implicated in this association.  For instance, fearfully attached women may believe that in order to be accepted by their husbands, they must demonstrate their autonomy.  They may expect to be rejected if they show vulnerability or seek emotional support.  These if–then scripts could prevent them from seeking support or bias their perception of interactions with their husbands, leaving them feeling unsupported and ultimately rendering them vulnerable to depression.  Alternatively, these women's negative beliefs about self and others may reflect the current climate of their marriages.  Conflicted marital relations may exacerbate both attachment insecurity and depression" Wiffen et al., 2001, page 586-87).  

Anxious-ambivalent individuals want intimacy but switch between hostility and dependency wher their partners behave in some unexpected or seemingly unsupportive manner.  It is thought that anxiety, rage and fearfulness experienced by the mothers of anxious-ambivalent children was communicated to them in various manners.  Bouncing back between fearing being of engulfed or overwhelmed versus becoming desperate with abandonment (desolation), they become predisposed to duplicate intimate relational patterns with new close relationships.  "Kohut referred to these persons as 'mirror hungry' in that they feel compelled to present themselves in such fashion as to obtain continuous confirming and admiring responses without which they feel worthless, hopeless and often helpless.  Ambivalently attached adults frequently experience intense neediness and are often frustrated in their efforts to find comfort or self-soothe.  They find it difficult to form and maintain intimate relationships (Hill, 1996)" (Hill, 2009, page 6-7).  Anxious-ambivalent individuals often get highly self-critical with relationship problems and become depressed.  Depressive symptoms and marital dysfunction may therefore be most common with anxious-ambivalent attachment style in individuals.  The relationship between attachment styles and depression and relationship health is stronger in women.  "…for women, the attachment style associated with depressive symptoms is a more important correlate of marital satisfaction than the depressive symptoms themselves, or that depressive symptoms are associated with a specific attachment style that is related to marital distress.  As such, secure attachment style, or the presence of a generally positive interpersonal evaluation of themselves and others, may provide women with an inner resource protecting themselves from marital distress given depressive symptoms."  Anxious-ambivalent women with pervasive self-doubt, low self-worth/self-esteem, and depressive symptoms, which make them more vulnerable to relationship problems (page 429-31).  Heene et al. "support the notion that helping couples to develop more safe and accepting perceptions of their partners and their relationship may increase individual and marital satisfaction (see also Cobb et al., 2001).  To reframe their internal working models, clients can be encouraged to explore expectations of the therapist and significant others, and the memories of earlier attachment figures" (page 434-35).

The therapist may consider if stereotypical differences between in how men and women experience and respond are relevant in a heterosexual couple.  A couple like Aubrey and Braydon seem to fit many of the theories and stereotypes discussed.  Involving a partner may be useful for uncovering harmful or illogical thinking and behaviors and as an active agent in the other partner's process.  The challenge of therapy with Aubrey and Braydon would be how to engage each in turn as active agents.  To shift from active aggression or avoidance to a more benign much less hopefully supportive relationship is more complex with a long history of dysfunction.  Therapy may be more productive simply by promoting a cooperative process, that must simultaneously preclude partners from blaming each other for their relationship issues.  The anxious-ambivalently attached individual may have many of the fearful anticipation and negative assumptions of the avoidantly attached/dismissive individual, but differ in having greater willingness to attempt intimacy.  A shift from avoidant/dismissive attachment to anxious-ambivalent attachment would be progression and perhaps, an appropriate intermediate goal for Aubrey and Braydon.  That a couple presents for therapy may be considered a function and consequence of lingering hope despite negative experiences.  The therapist works with and from this hope.  He or she may need to augment and validate the hope in the therapist-client relationship as well as in the partner relationship.  The attachment style will often apply to the functionality of the therapist to one partner and to the other partner.  Initial therapy may need to focus on creating some attachment security with each partner individually.  Getting Aubrey to have some faith in the therapist and getting Braydon to have some faith in the therapist, may be the bridge to creating it between the partners.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
(510) 614-5641 or (510) 582-5788
fax: (510) 889-6553
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