By Staci Weiner, Psy.D.

Apple Psychological, LLP.
www.applepsychological.com.

Choose to be Happily Married, How Everyday Decisions Can Lead to Lasting Love by Bonnie Jacobson, Ph.D., Publisher Adams Media, May 2010.

This is a relationship road map; a manual for relationships that leads to successful communication, listening skills, and ultimate connection between two people. Illustrating twenty-five crucial turning points, the author raises the reader’s consciousness about critical individual and relationship decisions.  Readers learn how to translate the abstract emotions of everyday life into concrete expressions, making them more manageable in the process.

Dr. Jacobson empowers readers to make conscious choices in moments of empathic disconnect between themselves and significant others as well as encouraging readers to explore inventive ways of working with conflict and constructive forms of aggressive expression. The approaches discussed are derived from attachment theory, neurobiology, and theories of healthy aggression and conflict resolution to help people manage their daily life without being a victim of their own history.

This work helps readers gain insight into some of the choices that can lead to lasting love including:

• Learning different ways to respond or react to conflict in the moment
• Learning  to pick and choose your battles and decide when and how to establish boundaries
• Developing new ways to be tolerant of your partner’s need for personal space, change, and his/her own family values
• Developing self-awareness and control with regard to your role in the relationship and your own style of interacting
• Establishing effective communication
• Sharing your thoughts and yourself
• Using intimate listening skills
• Supporting and empowering your partner
• Understanding the difference between joy and happiness and embracing what lasts

This book is a modern dissection of relationships that acknowledges how roles shift over time.  It can be immensely helpful to couples who struggle with communication and listening skills as well as those who have difficulty establishing and maintaining personal relationships. Enjoyable and easy to read, the author uses everyday examples to illustrate her points.  The Emotional Turning Point Test at the end of the book allows readers to gain insight into themselves.

There are several online Self-Help Book Clubs in which participants read selected chapters and discuss them with other readers and mental health professionals.  More information on the Self-Help book clubs can be obtained by going to www.applepsychological.com and www.drbonniejacobson.com.

By Dr Keely Kolmes and Dr. Dan Taube.

Our society and, indeed, the world, is becoming increasingly networked via the Internet, and mental health practitioners are beginning to rely more heavily on the World Wide Web. As this happens, reports of encounters with clients and treatment complexities have begun to emerge (Grohol, 2008; Hsiung, 2009). The increased visibility of and access to friend networks and public Internet postings has created new possibilities for intentional and accidental virtual contacts between therapists and clients. The growth of social networking and web-based information also raises the possibility of clients searching for and finding professional and personal information about psychologists, and for psychologists to search for and find similar information about clients.

The former concern has caused unease among mental health providers. Zur and Donner (2009), for example, explored the availability of large caches of online information about therapists and framed the access to such information as an issue of therapist transparency and disclosure. They outlined the difference between deliberate versus non-deliberate, verbal versus nonverbal, and avoidable versus unavoidable therapist disclosures. Zur and Donner noted that the motivations of clients who seek information on therapists can range from harmless curiosity to criminal stalking. They recommended that therapists using the Internet should remain aware that all of their online postings, blogs, chats, and other interactions may be viewed by clients and will be forever archived online. They further encouraged therapists to search online for information about themselves regularly to be sure what clients are discovering about them, and they made recommendations about how we should attempt to monitor and address concerns about our own privacy.

Increasingly, ethics commentators have turned their focus to the problems and promises of psychologists searching for information about applicants, clients, and others on the Internet. Behnke (2007) noted that some clinical training directors and graduate program faculty have started to use the Internet to search for information about trainees and applicants. He raised the question of how this third party information should be handled and he noted the risks related to psychologists shifting from a clinical to an investigatory role. Barnett (2009) focused on the potential for therapists to secretly access client information online. He defined such behavior as a boundary issue and suggested that these pursuits may violate an implied contract and may affect the public’s trust in psychologists, unless this behavior is clearly addressed in the process of informed consent.

Hughs (2009), on the other hand, asserted that it is not necessarily unethical to search for patient information online. Her argument was that if information was sought to promote patient care, rather than to satisfy a therapist’s curiosity, it could further a legitimate clinical interest. For example, if a client refused or was unable to provide historical information, an online search might be a reasonable way to obtain supplemental data.

Thus, there are ethical and practical issues emerging in regard to extra-therapeutic contacts on the Web. Theoretically, there are ethical hazards related to multiple relationships (APA, 2002), but such contacts may have the potential to benefit clients and treatment. Yet there is little in the way of empirical data about these risks and benefits. One of the only empirical investigations that has been conducted thus far was a study by Lehavot, Barnett and Powers (2010), that surveyed graduate psychology students to assess, among other things, the degree to which they sought online information about clients. The authors reported that some 27% of their participants engaged in this activity. They acknowledged that searching for client information has the potential both to have negative and positive influences on the clinical relationship.

The Current Research

In our current, ongoing survey, we aim to extend Lehavot et al.’s (2010) study to include a wide range of professionals (psychologists, marriage and family therapists, clinical social workers and psychiatrists) at a variety of training levels (e.g., clinicians in training, recent graduates, and experienced clinicians). We also hope to explore ethical issues faced by practicing psychotherapists who have had intentional and accidental extra-therapeutic encounters with their clients on the Internet.

Our study has been approved by the Institutional Review Board of Alliant International University. If you are interested in participating, you may access the survey and begin the Consent Process.

Our findings will be posted at the end of August, 2010 in several places: Dr. Kolmes website, Dr. Taube’s website,  and an interim report was presented at the California Psychological Association’s 2010 Convention in a session by Dr. Kolmes called Friending, Fanning, and Following: Findings on Client-Therapist Internet Interactions and their Influence on Treatment.

References

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073.

Barnett, J., (2009) Social Networking Sites, Clients, and Ethics: Dilemmas and Recommendations. [Lecture]. From International Conference on Use of the Internet in Mental Health, Montreal 2009. Retrieved from http://bcooltv.mcgill.ca/Viewer2/?RecordingID=27892

Behnke, S. (2007, January).  Posting on the Internet: An Opportunity for self (and other) reflection. APA Monitor on Psychology, 60-61.

Behnke, S. (2007, July/August). Ethics in the age of the Internet. APA Monitor on Psychology, July74-75.

Grohol, J. M. (2008, May 14). Social network may blur professional boundaries. Message posted to http://psychcentral.com/blog/archives/2008/05/15
/social-networks-may-blur-professional-boundaries/

Hsiung, R. (2009, May).  How to friend: Social networking Web sites for beginners [PowerPoint slides]. Retrieved June 19, 2009, from American Psychiatric Association Annual Meeting, http://mythreeshrinks.com/apa09/slides-hsiung.pdf

Hughs, L. (2009, May). Ethics Corner: Is it ethical to Google patients? Psychiatric News, 44, 9 & 11.

Lehavot, K., Barnett, J., & Powers, D. (in press). Psychotherapy, professional relationships, and ethical considerations in the MySpace generation. Professional Psychology: Research and Practice.

Zur, O., & Donner, M. B. (2009; January/February). The Google Factor: Therapists’ Transparency in the Era of Google and MySpace. The California Psychologist, 23-24.

Jeffrey Barnett

Jeffrey Barnett, Psy.D., ABPP is a Professor in the Department of Psychology at Loyola Univeristy Maryland and a licensed psychologist in practice in Arnold, Maryland. He is a Diplomate in Clinical Psychology and in Clinical Child and Adolescent Psychology of the American Board of Professional Psychology and a Distinguished Practitioner of Psychology in the National Academies of Practice. He is a recent past chair of the Ethics Committee of the American Psychological Association and has previously been chair of the Maryland Psychological Association Ethics Committee. Dr. Barnett has published numerous articles, chapters, and books on ethics and professional issues in Psychology and has given numerous presentations and continuing education ethics workshops for psychologists and other mental health professionals. His most recently published books include Ethics Desk Reference for Psychologists (APA Books, 2008, with Brad Johnson), Ethics Desk Reference for Counselors ( ACA Books, 2009, with Brad Johnson), and Financial Success in Mental Health Practice (APA Books, 2008 with Steve Walfish).

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Pennsylvania State University

Recently Meifen Wei wrote a very interesting News You Can Use (NYCU) feature on implications of attachment theory and research for counseling and psychotherapy (see the Division 29 website, http://www.divisionofpsychotherapy.org/). Her NYCU article focused on links between attachment and the development of coping styles and relationship patterns, as well as on understanding attachment-related aspects of the dynamics that underlie individuals’ emotional difficulties. Her article provided some very helpful tips on how psychotherapists can help those high on attachment anxiety and/or avoidance to change coping strategies that might not be working well and help them meet their needs in more satisfying ways. The goal of the present article is to talk about empirical work that helps to shed light on how client attachment might influence the process of individual psychotherapy with adults, with an emphasis on the role of attachment in the psychotherapy relationship. By better understanding how attachment-related dynamics might play out in psychotherapy, we might be better able to anticipate how our clients might experience therapy and help them get more from the experience of psychotherapy.

There has been a great deal of interest in attachment as a variable that can affect the process (and outcome) of psychotherapy (e.g., Daniel, 2006; Lopez, 1995; Lopez & Brennan, 2000; Mallinckrodt, 2000; Mohr, Gelso, & Hill, 2005). Most of the research has focused on the links between attachment and the working alliance. However, there has also been some research on clients’ attachment to the therapist, the role of attachment in transference and countertransference, and additional processes such as attachment-related differences in client memory for in-session emotion.

In order to understand the role of attachment in the psychotherapy relationship, it is important to understand how Bowlby (1988) conceptualized the psychotherapist as a secure base for the client. Bowlby argued that the attachment relationship becomes an attachment relationship as the client begins to experience the psychotherapist as a source of help, safety, comfort, and acceptance. The client, whose attachment system is activated because of the distress the client is experiencing, becomes attached to the psychotherapist; he or she begins to be able to use the therapist to explore and reflect on painful life events and feelings, knowing that the psychotherapist provides a secure base for this sometimes emotionally difficult process. Just as the presence of the attachment figure allows a child to go out and explore, the presence of the psychotherapist as a secure base for exploration allows the client to do the hard work of psychotherapy.

Bowlby (1988) believed that the purpose of psychotherapy is to accomplish five central tasks: (a) to use the therapist as a secure base from which to explore, (b) to come to understand how the client currently relates to other people and how those relationships are influenced by the client’s internal working models of attachment, (c) to examine the relationship with the psychotherapist as a way of better understanding unconscious working models and biases, (d) to reflect on how working models of attachment are rooted in childhood experiences with primary attachment figures, and (e) to use the relationship with the psychotherapist and the work of psychotherapy to change the older working models of attachment that were once adaptive but are no longer helpful. Revising the working models allows for better relationships and emotion regulation strategies to emerge. Without the safety of the therapist as a secure base, however, it is difficult for the client to do the work required in psychotherapy.

Thus, it is important for the client to attach to the therapist. Because the relationship with the therapist, however, is theorized to be strongly influenced by previous attachment experiences with important caregivers (Bowlby, 1988), the client’s attachment to the therapist may not necessarily be a secure attachment even with a therapist who is consistently warm and accepting. Sometimes, the initial attachment is an insecure attachment—but the hope is that over time if the psychotherapist consistently provides a secure base, the relationship will eventually shift to a secure one. We still need prospective studies with repeated measures to see if this is actually what happens in therapy, but clinical experience would suggest that this may be true.

Mallinckrodt, Gantt, and Coble (1995) developed the Client Attachment to the Therapist (CATS) measure. Mallinckrodt et al. conceptualized client attachment to the therapist in terms of three dimensions: secure, preoccupied-merger, and fearful-avoidant. Secure attachment reflects the degree to which clients tend to be able to use the therapist as a secure base. Preoccupied-merger reflects the degree to which clients tend to feel preoccupied with the therapist, longing for greater contact with the therapist. Fearful-avoidant attachment reflects the degree to which the client attempts to avoid disclosing in therapy because of fears of feeling ashamed or humiliated with a therapist who is experienced as rejecting and disapproving. Mallinckrodt (2000) explained how the three dimensions of the CATS are linked to the two dimensions typically used to conceptualize attachment in adults: attachment anxiety and avoidance (Brennan, Clark, & Shaver, 1998). Attachment anxiety involves a preoccupation with relationships, worry about being abandoned by others, and a desire for closeness that typically exceeds what others desire. Attachment anxiety tends to be associated with hyperactivating strategies of attachment and emotion regulation. Hyperactivating strategies may develop in the context of inconsistent caregiving, in which attending to distress, expressing distress intensely, and being on the alert for any sign of abandonment tends to maximize the overall availability of the caregiver (Kobak, Cole, Ferenz-Gillies, Fleming, & Gamble, 1993) Attachment avoidance, other hand involves a desire to avoid closeness with others and avoid interpersonal dependence (Brennan et al., 1998). Attachment avoidance is associated with deactivating strategies of attachment, in which the individual learns to avoid activation of the attachment system, including any associated experience or expression of emotion. Deactivating strategies of attachment are thought to develop in the context of caregivers who tend to reject bids for attachment, such that the individual learns that suppression of attachment needs keeps the caregiver from pulling away further (Kobak et al, 2003).

Mallinckrodt (2000) linked the CATS to the two-dimensional model of attachment (anxiety and avoidance; Brennan et al., 1998) by explaining each dimension of the CATS in terms of anxiety and avoidance. The Secure subscale of the CATS reflects the degree to which clients experience little attachment anxiety or avoidance with the therapist, and tend to use neither hyperactivating nor deactivating strategies of attachment. High scores on the Preoccupied-Merger subscale of the CATS reflects high levels of attachment anxiety with the therapist, and a tendency to display hyperactivating strategies of attachment with their therapists. Because there are few clients who tend to show a more “pure” avoidance (also called dismissing avoidance, Bartholomew & Horowitz, 1991) due to the fact that such individuals are unlikely to engage in helpseeking, there is no scale on the CATS that reflects “pure” avoidance with no attachment anxiety mixed in. The Fearful-Avoidant subscale, however, captures clients who tend to show a mixture of both high levels of both attachment anxiety and avoidance. For the clinician, these subscales are likely to conjure up images of clients who match the subscale descriptions.

Mallinckrodt, Gantt, and Coble (1995) found that greater secure attachment to the therapist was associated with higher working alliance scores, whereas fearful-avoidant attachment to the therapist was inversely related to working alliance. Studies of general adult attachment (not specifically attachment to the therapist) have found that both greater attachment anxiety (Mallickrodt, Coble, & Gantt, 1995) and higher levels of attachment avoidance (Kivlighan, Patton, & Foote, 1998; Parish & Eagle, 2003; Satterfield & Lydden, 1995, 1998) are linked to lower ratings of the working alliance in psychotherapy. Tying these two lines of research together, Mallinckrodt, Porter, and Kivlighan (2005) found that greater general insecurity in adult attachment was linked to lower security of attachment to the therapist, with both greater insecurity in adult attachment and greater insecurity in attachment to the therapist being linked to lower working alliance ratings. Decreased security of attachment was associated with lower levels of exploration and lower ratings of the session as smooth or deep (even after controlling for working alliance). In terms of how attachment is related to working alliance over time, Eames and Roth (2000) found that security of attachment (i.e., low attachment anxiety and avoidance) was related to higher initial ratings of the working alliance and positive perceptions of the working alliance over time. On the other hand, those who were high on both attachment and avoidance tended to have lower working alliance ratings (as rated by both therapist and client), and experienced more ruptures. Those clients who were high on either attachment anxiety or avoidance (but not both) tended to initially have lower working alliance ratings, but improved over time. These results provide some support for the idea that it may be helpful if the therapist is able to provide a secure base consistently over time.

Most of the research on attachment and the psychotherapy relationship has focused on the working alliance. One study, however, examined links between attachment to the therapist and transference in a study of clients in relatively long-term psychotherapy in the community (Woodhouse, Schlosser, Crook, & Ligiéro, 2003). This study found that clients who were high on preoccupied-merger attachment to the therapist, as expected, showed higher levels of transference overall and had more negative transference than those low on preoccupied-merger. There was no link between fearful-avoidant attachment to the therapist and transference. We had expected that secure attachment to the therapist would result in more accurate perceptions of the therapist and thus lower levels of transference. Surprisingly, we found that secure attachment to the therapist was linked to higher levels of negative transference. Upon reflection, we realized that perhaps this finding should not have been so surprising. We proposed that because clients who are securely attached to the therapist can view the therapist as a secure base, it is more likely that they will feel comfortable enough to explore more deeply, thus allowing negative transferential material to emerge. Perhaps the security of attachment to the therapist that allows clients to bring forth this transferential material also allows clients to gain insight into this material and shift internal working models of attachment as predicted by Bowlby (1988). More research will be needed, but the Woodhouse et al. findings are suggestive.

The research on attachment and countertransference has naturally tended to focus on the attachment styles of therapist-trainees (which is outside the scope of the present article), rather than clients. However, because of provocative findings that the attachment of the client interacts with the therapist-trainee attachment to predict countertransference behavior, I will also briefly mention two studies. Rubino, Barker, Roth, and Fearon (2000) asked therapist-trainees to respond to clinical vignettes of potential alliance ruptures representing clients with different attachment styles. Rubino et al. found that therapists high in attachment anxiety were less empathic, especially if the client was either secure (low attachment anxiety and low avoidance) or if the client was high in avoidance. Mohr, Gelso, and Hill (2005) found that therapist-trainees’ supervisors rated trainees high in attachment avoidance as exhibiting greater hostile countertransference behaviors if the client was high on attachment anxiety. On the other hand, those trainees who were high on attachment anxiety tended to show higher levels of hostile countertransference when clients were high on avoidance.

Thus far the focus has been on reviewing the research relevant to the psychotherapy relationship, but client attachment may also affect other aspects of the process of psychotherapy, such as clients’ memory for emotion that occurs within the psychotherapy session. Clinical observation would suggest that clients differ in how they remember in-session emotional events. Some clients seem to minimize in the next session what they felt during an important and emotional event in therapy the week before, whereas other clients seem overwhelmed as they remember a productive, yet emotional event from a prior session. Bowlby (1969/1982) theorized that emotion and emotion regulation are an important component of attachment working models and, as described above, research has shown that attachment strategies may be either hyperactivating (with vivid experiences and expressions of emotion and high attention to mood) or deactivating (tending to avoid both experiences and expressions of emotion; Kobak et al., 2003). Woodhouse and Gelso (2008) found that, as expected, volunteer clients who were high in attachment anxiety tended to show a memory bias in which they tended to remember negative emotion linked to a client-selected, unpleasant-emotion therapy event as significantly more negative than did volunteer clients lower in attachment anxiety. Results showed that clients tended to minimize negative affect that occurred during the session (regardless of level of attachment anxiety), but that volunteer clients who were high in anxiety tended to do so less than other clients. Clients high in anxiety were also found to ruminate on their mood to a higher degree than other clients. It is possible that such a hyperactivating memory bias that allows memory for negative in-session emotion to remain high may interfere with experiencing the therapist as a secure base. For example, if when in-session negative affect is high, clients who are high in attachment anxiety minimize that negative affect to a lesser degree than would those who are lower in attachment anxiety, this lower level of minimization may leave such clients with a sense that therapy is an emotionally uncomfortable experience without much comfort from the therapist. It may be important for clinicians to take this tendency into account and help clients high in attachment anxiety to later process negative affect that occurs in session.

Higher scores on avoidance were associated with more negative initial ratings of negative emotion in conjunction with the client-selected, unpleasant-emotion therapy event, although there was no evidence that volunteer clients high in attachment avoidance minimized that emotion the following week (Woodhouse & Gelso, 2008). At the same time, however, these clients reported difficulty naming and categorizing their moods. Thus, clients high in avoidance may find it difficult to experience the therapist as a secure base if they experience higher levels of negative affect in session (than clients scoring lower on avoidance), yet at the same time find it difficult to identify and categorize these feelings. Such clients may experience counseling as difficult and confusing. It may be helpful for psychotherapists to consider ways of helping clients high in avoidance make sense of experiences of negative affect that occur in session, even if the clients do not tend to bring these issues to the attention of their therapists.

More research will be necessary to continue to understand how attachment is linked to the process of psychotherapy. However, results thus far paint a very interesting clinical picture. Readers who are interested in reading more about clinical applications of attachment theory and research may enjoy reading a book edited by Obegi and Berant (2009) that has recently been published. This book effectively integrates clinical material and research findings in a way that will be of great interest to clinicians, and explores the relevance of attachment theory across a variety of theoretical orientations (including psychoanalytic, interpersonal, and cognitive-behavioral therapy, as well as emotion focused couple counseling).

References

Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four category model. Journal of Personality and Social Psychology, 61, 226-244.

Bowlby, J. (1982). Attachment and loss:  Vol. 1: Attachment (2nd ed.). New York:  Basic Books. (Original work published 1969)

Bowlby, J. (1988). A secure base:  Parent-child attachments and healthy human development. New York:  Basic Books.

Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult attachment:  An integrative overview.  In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships (pp. 46-76).  New York:  Guilford Press.

Daniel, S. I. F. (2006). Adult attachment patterns and individual psychotherapy: A review. Clinical Psychology Review, 26, 968-984.

Eames, V., & Roth, A. (2000). Patient attachment orientation and the early working alliance—A study of patient and therapist reports of alliance quality and ruptures. Psychotherapy Research, 10, 421-434.

Kivlighan, D. M., Jr., Patton, M. J., & Foote, D. (1998). Moderating effects of client attachment on the counselor experience-working alliance relationship. Journal of Counseling Psychology, 45, 274-278.

Kobak, R. R., Cole, H. E., Ferenz-Gillies, R., Fleming, W. S., & Gamble, W. (1993). Attachment and emotion regulation during mother-teen problem solving: A control theory analysis. Child Development, 64, 231-245.

Lopez, F. G. (1995). Contemporary attachment theory: An introduction with implications for counseling psychology. The Counseling Psychologist, 23, 395-415.

Lopez, F. G., & Brennan, K. A. (2000). Dynamic processes underlying adult attachment organization: Toward an attachment theoretical perspective on the healthy and effective self. Journal of Counseling Psychology, 47, 283-300.

Mallinckrodt, B. (2000). Attachment, social competencies, social support, and interpersonal process in psychotherapy. Psychotherapy Research, 10, 239-266.

Mallinckrodt, B., Coble, H. M., & Gantt, D. L. (1995). Working alliance, attachment memories, and social competencies of women in brief therapy. Journal of Counseling Psychology, 42, 79-84.

Mallinckrodt, B., Gantt, D. L., & Coble, H. M. (1995). Attachment patterns in the psychotherapy relationship: Development of the Client Attachment to Therapist Scale. Journal of Counseling Psychology, 42, 307-317.

Mallinckrodt, B., Porter, M. J., Kivlighan, D. M., Jr., (2005). Client attachment to therapist, depth of in-session exploration, and object relations in brief psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 42, 85-100

Mohr, J. J., Gelso, C. J., & Hill, C. E. (2005). Client and counselor trainee attachment as predictors of session evaluation and countertransference behavior in first counseling sessions. Journal of Counseling Psychology, 52, 298-309.

Obegi, J. H., & Berant, E. (2009). Attachment theory and research in clinical work with adults. New York: Guilford.

Parish, M., & Eagle, M. N. (2003). Attachment to the therapist. Psychoanalytic Psychology, 20, 271-286.

Rubino, G., Barker, C., Roth, T., & Fearon, P. (2000). Therapist empathy and depth of interpretation in response to potential alliance ruptures: The role of therapist and patient attachment styles. Psychotherapy Research, 10, 408-420.

Satterfield, W. A., & Lyddon, W. J. (1995). Client attachment and perceptions of the working alliance with counseling trainees. Journal of Counseling Psychology, 42, 187-189.

Woodhouse, S. S., & Gelso, C. J., (2008). Volunteer client adult attachment, memory for in-session emotion, and mood awareness: An affect regulation perspective. Journal of Counseling Psychology, 55, 197-208.

Woodhouse, S. S., Schlosser, L. Z., Crook, R. E., Ligiéro, D. P., & Gelso, C. J. (2003). Client attachment to therapist: Relations to transference and client recollections of parental caregiving. Journal of Counseling Psychology, 50, 395-408.