My theoretical orientation is psychodynamic. I specifically subscribe to the teachings of John Bowlby’s attachment theory and the work of Diana Fosha, who has formulated Accelerated Experiential-Dynamic Psychotherapy (AEDP). My reason for using a psychodynamic orientation is that I have found it to be successful in treatment settings and to resonate with my personal beliefs about human beings and interpersonal relationships.
I first provide a basic summary of psychodynamic/psychoanalytic theory because attachment theory and AEDP both originate from it. Psychoanalytic theory according to Freud (1926) attributed the development of attachment to the satisfaction of the child’s instinctual drives by the mother. Freud postulated that the propelling force of the personality is to satisfy its needs or drives, such as the need for food and sex. Freud stated that the emotional bond between mother and child forms as a result of the infant’s attachment to the mother as provider of food. Anxiety arises when an individual fears that his/her needs might not be met. In order to deal with anxiety, defense mechanisms are utilized, which involve denying the anxiety in a variety of ways so that the individual does not have to deal with its full impact. There are eight types of defense mechanisms that Freud describes (Freud, 1932). He also described psychosexual stages of development, which are oral, anal, phallic, and genital. Additionally, Freud (1923) identified the three components of the psyche, the id (acting on one’s basic impulses), the superego (the curtailer of impulses), and the ego (which moderates between the other two). Freud believed that making the unconscious conscious through free association would free the patient of neurosis.
One example of psychodynamic psychotherapy that informs my approach to treatment is the work of Luborsky (1984). Luborsky recommends identifying a core conflictual relationship theme that operates unconsciously. The conflict may arise from differences in the wishes of the id and the superego and is assumed to originate in one’s early relationships. Re-experiencing early relationship difficulties in therapy through transference, and resolving them, is the work of therapy. The therapist interprets defenses and transferences so that the client can relate to others in a more realistic manner.
Attachment theory is an outgrowth of psychoanalytic theory. A basic summary of attachment theory is as follows. Bowlby (1973) defines attachment as “any form of behavior that results in a person attaining or retaining proximity to some other differentiated and preferred individual, who is conceived as stronger and/or wiser” (p. 203). He describes attachment from an ethological viewpoint. Attaining proximity to the mother/caretaker ensures protection, which provides many survival advantages, one of which is to avoid being eaten by predators. Infants will seek their parents particularly in times of distress. Attachment-seeking behavior stops upon contact with the caretaker.
Bowlby (1969/1982) proposed that internal representational models are developed which allow anticipation of future caretaking behaviors. The child relies on this model when deciding what type of attachment behavior to use in specific circumstances and with particular individuals. He suggests that attachment behaviors are an outgrowth of a child’s representational models (also referred to as internal working models). According to Bowlby, internal working models are accurate cognitive representations of interactions between the child and the caretaker. Bowlby (1973) states that if a child experiences a dependable and consistent relationship with an attachment figure, and is able to use that person as a secure base, then the child will develop confidence in the self and trust in others. If, however, a caretaker is unavailable for an extended period of time, the child feels threatened and hostile. Children with unavailable caretakers expect that attachment needs will not be met.
According to Bartholomew and Horowitz (1991), there are three types of insecure attachment and one type of secure attachment. The insecure attachment style labeled preoccupied attachment will be explained here as it accurately describes the attachment style of the client that will be presented in this case study. Preoccupied attachment is a feeling of unworthiness or unlovability combined with a positive evaluation of others.
Individuals with preoccupied attachment styles strive for self-acceptance by gaining the approval of valued others. Such individuals are considered by others to be warm in interpersonal relationships. Individuals with preoccupied attachment style tend to blame themselves for perceived rejections in order to maintain a positive view of others. They are emotionally reactive and expressive and seek out the support of others when upset. They are dependent on others for self-esteem and have jealousy and separation anxiety. They often see others as unreliable or unavailable. Relationships are very important to them and they are clingy and dependent and also dominant. Individuals with preoccupied attachment styles tend to have difficulties becoming close to and relying on others due to their neediness, which pushes others away. According to research by Stein, Jacobs, Ferguson, Allen, and Fonagy (1998) on the type of parenting styles associated with children with preoccupied attachment, such individuals are likely to have had overprotective, inept, and inconsistent parenting. They remain emotionally enmeshed with their family and shift between idealizing and devaluing their parents.
Ainsworth (1989), an important attachment theorist and researcher, states that parents, peers, siblings, and romantic partners may all be attachment figures over the course of a lifetime. The defining features of infant-mother attachment characterize most love relationships: a desire for closeness to the attachment figure, especially under stress, sense of security upon contact, and distress when threatened with separation.
There is a general assumption in the literature that attachment style remains relatively stable over the life span (Eagle, 1996), and Bowlby (1973) states specifically that early models of attachment persevere throughout life. Attachment styles make the world predictable and help the child relate to its caretaker adaptively.
I have chosen to use attachment theory when conceptualizing and treating cases because it is easily observable in human infants’ interactions with their caretakers and there has been much empirical research that confirms its validity. I have utilized the theory in therapy and found that it helps individuals to understand their relationship patterns.
AEDP as described by Diana Fosha (2000) postulates that the anxiety which causes the defense mechanisms noted by Freud and leads to the defense mechanism of repression can be experienced and released. She states that through the use of radical empathy by the therapist, the client can experience emotions that have been repressed due to anxiety and release them, thus transforming the patient’s emotional state and thus behavior. Fosha also recommends the use of confrontation by the therapist of the patient’s negative patterns so that the patient can more clearly see his/her own behavior and change it. Finally, Fosha recommends the use of mind-body work, which helps the person locate emotions in his/her body and focus on them in order to fully experience them and release them. This technique is described in depth in the book Focusing by Eugene Gendlin (1981). A typical question that Fosha recommends asking is “where in your body do you feel that?”
In my experience providing psychotherapy, I have found these techniques to be extremely useful in helping the patient to access emotion that is denied and to release it, resulting in behavioral changes. It is for this reason that I have chosen to incorporate it into my practice.
Psychodynamic theory can be compared with an alternative approach to psychotherapy, that of Cognitive Behavioral Therapy (CBT). CBT consists of a combination of behavioral and cognitive theories of therapy.
Behavioral theory as it pertains to CBT involves classical conditioning. Classical conditioning can be understood with the example of Watson and Raynor’s (1920) classic experiment with “little Albert” whom they taught to be afraid of white rabbits and rats by pairing them with a loud noise that naturally caused fear. Eventually, Albert generalized a learned fear of white rabbits and rats to all white fluffy things. Learning theory (Watson & Raynor) also perceived the mother-infant bond to develop as a result of the pairing of the mother’s presence with need satisfaction.
Aaron Beck (1976) developed cognitive therapy. He hypothesized that depression and other mood disorders result from negative self-talk and distorted beliefs about the self. Beck believed that depression is caused by self-devaluation, a negative view of life, and pessimism about the future. He stated that a minor event can be blown out proportion by negative self-talk. Beck stated that changing cognitions about events can effectively treat depression and therefore prescribed challenging a patient’s interpretations of events.
He focused on patient’s tendencies to exaggerate bad events and minimize good ones, and he recommended asking the patient do some action outside of therapy that tests his/her beliefs about him/herself. Even if the patient’s beliefs are confirmed, the patient can see that they survived the situation, which can result in improved self perception and less negative emotion.
CBT involves combining behavioral techniques, for example, treating fear using systematic desensitization (pairing relaxation with a feared stimulus), with cognitive techniques such as challenging a patient’s negative thoughts. It has been shown to be effective through empirical studies. It is different from psychodynamic theory in its approach to therapeutic progress, as it involves changing a client’s cognitions rather than a client’s unconscious patterns of behavior through analysis of transference. The therapeutic relationship is not the main instrument of change, as it is in a psychodynamic therapy.
I have chosen to use a psychodynamic approach, specifically incorporating attachment theory and short-term dynamic therapy, which I have found to be the most useful approaches in psychotherapy. On occasion I do borrow some techniques from CBT, for example, relaxation techniques. I have also found that instructing a client to repeat a phrase such as “May I be at ease” when that client is calm creates an association between a calm state of being and that phrase, so that repeating it in stressful times can induce a feeling of calm. Additionally, when working with the parents of children, I instruct them to look at the ABCs, or antecedent behavior and consequence, of a child’s actions in order to foster a better understanding of the child’s behavior.
CBT has a place in my practice of psychotherapy, but it is not my main theoretical orientation. It is particularly useful in specific settings and with specific patients for whom psychodynamic technique is not recommended, for example, with individuals with major mental illnesses such as schizophrenia or with personality disorders such as antisocial personality disorder.
Attachment theory is described in Bowlby’s many in-depth works, for example, Attachment and Loss (Bowlby, 1969, 1973, 1980). It is based on his observations of the animal world and the human world of infant–caretaker interactions. A lot of empirical research confirms attachment theory. For example, Ainsworth, Blehar, Waters, and Wall (1978) found that mothers of securely attached infants were sensitive to the infants’ signals and showed warmth in their interactions. In contrast, mothers of insecurely attached infants were inconsistent and lacked sensitivity to their infants’ needs. She describes such mothers as averse to physical contact and as exhibiting hostile and critical behavior towards their infants. Research has also found that an infant’s attachment style is linked to their social emotional adjustment. For example, secure 2-year-olds are more autonomous and competent in problem-solving situations than non-securely attached children (Matas, Arend, & Sroufe, 1978). Dismissing children were likely to be described by teachers as distant and withdrawn or hostile and aggressive (Sroufe, 1983).
Attachment theory can also be used to understand attachment style to romantic partners as evidenced in the work of Hazan and Shaver (1994).
In terms of research on attachment theory and psychotherapy, there is some research on this subject although more research is clearly needed. Much understanding of adult attachment style as developing from childhood attachment style, along with means of measuring it, is based on the research of Mary Main (Main, Cassidy & Shaver, 1985). Main’s work on a narrative about one’s family of origin indicated that a cohesive narrative indicates secure attachment style better then the actual content of the narrative. This finding can be applied to therapy in that it informs a therapist’s ability to interpret the cohesiveness of a patient’s narrative about his/her family of origin. There is research on the relation between psychoanalysis and attachment theory (Eagle, 1995) and on the application of attachment research to the practice of psychotherapy (Sperling & Lyons, 1994). There is a study that finds security of attachment to be related to early therapeutic alliance (Goldman & Anderson, 2007). There is also research on using attachment theory to inform clinical formulation, as attachment style can be considered a risk factor for psychopathology (Sroufe, 1989). Furthermore, therapy takes place in the context of a therapeutic relationship, and therefore is affected by the dynamics of the patient’s attachment style (Slade, 1999,) and so an understanding of the patient’s attachment style can shed light on the patient’s behavior in psychotherapy.
There is a lot of research on the effectiveness of psychodynamic psychotherapy, upon which attachment theory is based. An example of this is Interpersonal
Psychotherapy (IPT) which is psychodynamic and the most studied psychotherapy in existence. There are 150 empirical studies supporting the effectiveness of IPT (Stuart, Robertson, & O’Hara, 2006).
AEDP has been described in length in Diana Fosha’s (2000) book. Fosha has also published qualitative articles on AEDP (Fosha, 1995; Fosha & Slowiaczek, 1997). There is presently no empirical work that I am aware of on AEDP; the writings about it are qualitative. Empirical research is needed on this treatment in order to prove its effectiveness empirically. AEDP is, however, based on Short-Term Dynamic Therapy (STDP), which has been researched quantitatively in an extensive manner (e.g., Junkert-Tress, Schnierda, Hartkamp, Schmitz, & Tress, 2001).
In her writings, Fosha posits that anxiety inhibits the experience of affect and the manner in which empathy helps a client to experience affect that has been disowned due to intense anxiety. Fosha describes the process of “moment to moment tracking” which creates an environment of safety and being known, which results in therapeutic transformation. Fosha uses case examples and clinical vignettes to illustrate her theory.
Additionally, there is more than one type of evidence for a treatment. I highly value empirical research; however, psychodynamic psychotherapy has traditionally relied on clinical experience and case studies. I and my psychotherapy supervisors have found attachment theory and AEDP to be very helpful in guiding therapy. My patients have concurred in their feedback of the effectiveness of therapy.