A Clinical Case of an Avoidant Attachment Doris k. Silver Man, Phd

Psychoanalytic Psychology 2011, Vol. 28, No. 2, 293–310

© 2011 American Psychological Association 0736-9735/11/$12.00 DOI: 10.1037/a0022342

A CLINICAL CASE OF AN AVOIDANT ATTACHMENT Doris K. Silverman, PhD  New York University and Institute for Psychoanalytic Training and Research

Whereass the Wherea there re is con consid sidera erable ble inf inform ormati ation on on att attach achmen mentt the theory ory and its research, the description of a case of avoidant attachment and its detailed clinical process is rare. The nature of these patients’ insistence on independence and self-sufficiency, their lack of admission of distress often linked to dissociation, and their dismissiveness of others, minimize the need to seek  treatment. Nonetheless, such patients often are experiencing chronic duress and require assistance because of their incapacity to moderate and stabilize their emotional states. I describe a patient who came to treatment because of  his panic attacks. His long-standing belief in his self-reliance and autonomy, a coping mechanism that evolved very early in his life, was an important therapeutic consideration. Early maladaptive interactions between his primary caregiver and him led to an internalized model of avoidant relationships. Because of such extreme insensitivities and misattunements on his mother’s part, he developed a reliance on self-regulation. This stratagem masked a need for interactive regulation from a caregiving other when he was stressed. This feature of our therapeutic work was an important focus. Those who demonstrate an avoidant/dismissive interaction are difficult to deal with therapeutically and the theoretical and clinical implications of this attachment are explored. In a lengthy analytic treatment, different psychoanalytic ideas were offered to the patient. Nonetheless, this case highlights the usefulness of attachment theory and its attendant therapeutic interventions. Keywords: avoidant attachment case, attachment theory and clinical process,

psychodynamic, trauma, self-sufficiency This article was published Online First February 28, 2011. Doris Do ris K. Sil Silver verman man,, PhD PhD,, New Yo York rk Un Unive iversi rsity ty Pos Postdo tdocto ctoral ral Pro Progra gram m and Ins Instit titute ute for Psychoanalytic Training and Research. The findings in the manuscript have not been previously published and that the manuscript is not being simultaneously submitted elsewhere. I wish to thank David Wolitzky for his careful reading, and helpful comments to an earlier draft of this paper. Correspondence concerning this article should be addressed to Doris K. Silverman, PhD, 315 Central Park West, New York, NY 10025. E-mail: [email protected]

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The attachment system research has provided us with information on the quality of  emotional relationships and the resultant emotional dysregulation when these bonds are distressed and seriously ruptured in childhood. A considerable amount of empirical research has contributed to the description of adaptive and pathological styles of  attachment, its etiology of these styles, the contributing sociological issues, as well as its clinical implications for both children and adults (Diamond, Clarkin, Levin, Levy, Foelsch, & Yeomans, 1999). Seriously insecure child attachments have been the subject of much investigation and it has provided cautious predictions about future pathology. However, there is a limited literature describing therapeutic interventions especially with adults (Muller, 2009; for contrast though see, e.g., Sable, 2000; Slade, 1999, 2000; Wallin, 2007; Weiner, 2003; for additional therapeutic vignettes see also Obegi & Berant, 2009 and Jurist, Slade, & Bergner, 2008.) Although I have included Slade (1999), hers is a qualified position on attachment as a therapeutic tool characteristic of the thinking of many attachment theorists; she understands it as providing a broad framework for understanding patients not as a theory that has specific clinical applications. Currently attachment interventions with extremely avoidant adults are primarily limited to those who have been seen in group treatment (Kirchmann et al., 2009) or mandated therapy for aggressive and violent behavior (Lawson & Brossart, 2009) or inpatient treatment (Fonagy et al., 1996; Muller & Rosenkranz, 2009; Schauenburg et al., 2010). There appears to be minimal to moderate success for these individuals. The nature of avoidant attachments—the dismissiveness of conscious interest in attachments, the emphasis on maintaining an experience of independence and self-sufficiency, and the individual’s fearful avoidance of others diminishes therapeutic contact and positive outcome in treatment. Obegi and Berant (2009) agree that avoidant adults “have misgivings about professional support”, they posit the need for knowledge about “specific kinds of interventions” that would be therapeutically helpful (p. 464). This paper addresses the issue. Whereas I am primarily focused on an avoidant attachment style, there are no pure attachment strategies. Early interactions with mothers and fathers, for example, can provide different attachment relationships with each of them (Belsky, 2006; Bretherton, Lambert, & Golby, 2005; Hesse & Main, 2000). Particular stressful engagements can alter a gained attachment style 1 (also see later discussion). This paper discusses a clinical case, that of Mr. K who demonstrated an avoidant pattern of attachment. His early and enduring habituation to his dismissiveness of  interpersonal experiences, as an outgrowth of his initial maladaptive dyadic interactions, provided meager development of affect modulation. In his treatment, I addressed his strong unconscious maternal connection as well as help him cope with erratic, rapid escalating emotions, and negative, suspicious feelings toward people. I employed both an attachment perspective and a psychodynamic orientation. I used both because as a patient with significant pathology, as Mr. K demonstrates, he typically exhibits comorbidity, that

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Change and consistency exist in the course of the developing individual. Highly stressful events can have a powerful negative effect on the growing child and at times, alter his or her attachment classification. Nonetheless, the ability to cope with such stressors and to return to relative stability subsequent to a high stress event can be understood as a function of the child’s initial secure attachment status (Sroufe et al., 2005). Thus a stratagem of attachment can alter, but there is also considerable stability.

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is, demonstrating more than one disorder, thus the need for a variable approach. 2 In other words, I also suggest that one approach does not fit all and neither is it effective for an individual patient. I also recognize that Bowlby’s attachment theory paid less attention to unconscious desires and the role of fantasy, 3 both of which I consider important features of Mr. K’s development. Although my therapeutic stance might be considered a multimodel one (Silverman, 1986), my emphasis in this communication is particularly on the helpfulness of an attachment perspective. I offer an elaborate and detailed description of the kinds of issues that patients who demonstrate an avoidant attachment are likely to present and provide options that appear effective for clinical work. A good deal of what has taken place in a long treatment is not discussed. There are undoubtedly other theoretical perspectives that our current pluralistic psychoanalytic world would consider relevant for such a case. For example, Feldman (2009) might discuss claustrophobic and agoraphobic issues, relationalists might highlight the recognition of the subjectivity of the analyst as creating a potential for the development of empathic coconnectivity, 4 and self-psychologists might focus on pathological self  issues that are ascendant. Wallin (2007) has suggested, when working with an attachment perspective, that the therapist’s vulnerable self disclosures might facilitate a readiness to tolerate vulnerabilities in the patient. In contrast, the stance I maintained with the patient allowed Mr. K to experience me as strong, capable, and emotionally stable. This minimized his contempt, derisiveness, and discard of me as he readily did with others, and

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A recent study (Johansson et al., in press) has reported that those patients who demonstrate a low level of object relations and personality disorder were considerably helped by the therapists’ use of transference interpretations. Insight was also a key ingredient for change. These two features are relevant components of a psychodynamic orientation. Although there is past research challenging the focus on transference interpretations as effective change factors, there is increased parsing of the therapeutic process which reflects that the use of transference may be beneficial for some patients (Piper, Azim, Joyce, & McCallum, 1991). Support for this view emerges from the work of  Blatt and his associates (Blatt & Luyton, in press). An avoidant attachment personality has features in common with what they have labeled as an introjective disorder. They report that the “basic issue for introjective patients is to achieve separation, control, independence and self definition and to be acknowledged respected and admired. . .They have difficulty managing affect, especially anger and aggression toward self and others” (p.23). This group of patients benefit from long-term insight oriented treatment. 3 Whereas Main and her colleagues have moved to the level of representation (1985, 2000), her concept of representation is different from the one utilized by a traditional psychoanalytic view. Main’s idea of representation in the child is a function of the mental state of the parent. It is invariably from within the internal psychic conflict of the parent that potential risk of later pathology exists for the child. Such hazards for the child can occur even with a sensitive and responsive parent but one who has suffered from her own traumatic experiences. Main’s understands such transmissions occurring via the parent’s occasionally alarming the infant with exhibitions of frightened, dissociated, or other kinds of anomalous behavior (Hesse & Main, 2000). The child’s unconscious fantasies are related directly to the mother’s traumatic past. A psychoanalytic understanding of  representation does not eliminate the role of the parents. However, the primary focus is on the unconscious fantasies generated within the child that color, idealize, or negatively distort parental representations. Unconscious self-needs, wishes, defenses, and compromise-formations of the child shape these representations. Whereas both positions recognize parental inputs shaping representations, the relative tilt of each is different. Attachment theories understand unconscious fantasies primarily as fashioned by parental responses, and psychoanalytic understanding gives greater input to the child’s own emotional needs and fantasies shaping representations. 4 For a different relational perspective, more consistent with the view advocated in this paper, see Slochower, 1996).

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more important, it allowed him eventually to rely on me to maintain his sense of security. Such a therapeutic position is equivalent to Kohut’s (1977) idea of the need for and effectiveness of an idealized self-object. I underscore the significance of grave difficulties with affect regulation which are an outgrowth of an avoidant attachment. Initially, I present clinicians’ objections to attachment research. I then describe what I believe is essential about the attachment system, and finally I offer a clinical case example. Many in our field express interest in the attachment system; however, it has been my experience and that of some of my colleagues (e.g., Morris Eagle, personal communication) that analysts are inclined to maintain limited interest and even dismissiveness of  attachment theory as a useful clinical tool. In part, such negative considerations arise from its empirical base, which leads analysts to stigmatize it and reduce the work as a limited, conscious, behavioral system, preoccupied with issues of temporary separation and loss, as well as, from a belief that a focus on the attachment system reflects a restricted recognition of a wide range of affective experiences related to psychosexual stages, and a minimization of the broad, rich, complex features of psychic life and human development. It is infrequent to hear that knowledge about infant research and in particular the attachment system and its potential applications can add richness and complexity to psychoanalytic technique. Yet, there is a good deal of overlap between the attachment system and psychoanalysis. Although it is not my primary focus in this article, it should be mentioned that most neurobiologists now recognize that early experience, especially between mother and infant influence our patterns of brain connections and these patterns contribute to shaping our personality, social interactions, and mental health in general (For an in depth explication of similarities and differences see Fonagy, 2001). Thus, there is a subtle, complicated relationship between the brain and behavior that Freud, the original neurologist, recognized (Silverman, 2010). The attachment system addresses the psychological nature of these early interactions. As Fonagy, Gergely, Jurist, and Target (2002) have written, the manner in which the child experiences his environment, that is, the nature of the child’s attachment, can act as a filter moderating the child’s genotype into its phenotype. However, what I want to focus on is the considerable misunderstanding about the nature of the attachment system. The attachment system is an independent behavioral system with its own organization. It is a developing system autonomous from drives and wishes, although they can eventually interdigitate with each other. In an example I proffer, I plan to demonstrate the advantage of considering the different systems and their clinical usefulness. There are benefits that can be derived when analysts are able to use the early developmental perspective that the attachment system offers, as well as a consideration of  sensual, sexual, aggressive wishes and core self issues. The attachment system as it is currently understood is primarily an affect-regulating system. I want to make it clear that from my perspective, the attachment system does not address all issues between the mother and her child. I believe its principle relevance concerns affect regulation. I do not emphasize it as a way of protecting the infant from predation. That may have been an early evolutionary advantage; it certainly is not relevant now. From my point of view, there are the physiological benefits that mother and infant engage in, for example, various forms of homeostatic regulation, such as warmth, nursing, holding, and sleeping, which are requirements for the infant’s survival. The psychological component is the regulation of the infant’s emotional state. I think of both the physiological and psychological systems as simultaneously beginning with the birth of the neonate. Both are part of the attachment relationship. The infant, and his or her mother,

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orchestrate a particular interactive pattern. The infant with his own biologicalphysiological state system and specific needs, and mother with her unique biologicalpsychological sensitivities develop a coordinated pattern of interaction over the course of  their first years. The infant is preprogrammed to discriminate a range of expressive behaviors in the caregiver and to respond with utterances, gestures, lip and tongue movements and full-body reactivity (Trevarthen, 1980; Tronick, 2007b). There is a nonconscious feedback system, including mutual adequate cuing and responsiveness that offer the infant opportunity for both interactive regulation and self regulation of affect. In these ways the mother is available as a modulator and she is offering the infant an experience of self regulation. Thus, learning about affect regulation is occurring in the infant. It is what has been labeled as “ implicit relational knowing” (Stark, 1977; Stern, 1977; Tronick, 1997). Embedded in this interaction is the unconscious development of an optimal experience of security for the infant. By this I mean that contained in this model is the child negotiating the adaptive way of maintaining a vital connection to his or her caregiver. Out of their different systems of coordination emerge certain predictable and habitual ways of fitting together. Thus the infant learns and develops forms of interactive regulation and self regulation that are tolerable for both mother and child and these become internalized. The developing attachment system has an important contributing feature providing a mental model of dyadic interaction. Eventually what occurs are unconscious organizing principles about interactive experiences. Such internalization is akin to what analysts have labeled as psychic representations, except that in the instance of understanding the attachment system, there is dyadic internalization. Currently, there is more recognition of such interactive experiences that are schematized, for example in Stern’s concept of RIGS (representation of interactions that are generalized) or Kernberg’s self-other affective units), or Winnicott’s notion that there is no baby without a mother. Mental models occur on the procedural level for the infant and unconscious fantasy meanings eventually become assimilated into it. If this interaction has worked reasonably well, then when the infant feels fear or anxiety, initially he or she will seek-out the mother who can reduce the anxiety, once again the prototype of the affect regulating feature of the attachment relationship. Over time the internalized mental model of a secure attachment increasingly helps to stabilize the child’s tense states. Disruption and dysregulation in the infant occur when the mother is unable to function as an emotional container. Psychopathology usually follows when a child’s regulatory system is excessively maladaptive. When life experiences do not alter this pattern, and when it is severe, the detrimental influence on intimacy, bodily concerns, affective experiences, sense of self, social skills, and needs and defensive structures become dominant and seriously limit the child’s effectiveness in dealing with the world. Neuroscience research appears to indicate that prolonged stress does such inhibitory damage to brain development that memory of early events can be permanently lost (LeDoux, 1996). Whereas cognition may disappear, the body speaks in that such states lead to chronic stress and emotional dysregulation. (Cortina, 2003). Cortina further suggests that such stressful experiences lead to avoidant responses and dissociative strategies in order to deal with their ineffective and disruptive emotional states. Undoubtedly, these children need their caregivers but they have been rebuffed and rejected and have developed negative, aversive strategies. Their responses can be demonstrated in the strange situation by one year of age. In reunions, avoidantly attached children appear indifferent to the reappearance of their mothers and focus on play with their toys (Sroufe

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& Waters, 1977). However, what belies their indifference are their elevated cortisol levels (Spangler & Grossman, 1993), indicators of their stress. The avoidantly attached child’s model appears to be resistant to change (Haggerty, Siefert, & Weinberger, 2010). New interactions tend to be incorporated into the early avoidant schema. As the authors suggest “new information are processed and interpreted “in a manner that is consistent with [their early internal working models]” (p.29). It is important that these authors indicate that not only can new experiences readily become assimilated into old schemas but, in addition, “new experiences can influence how past experiences are reconstructed and recalled.” (p. 29). Thus, interpersonally avoidantly attached (or dismissively attached) people tend not to turn to or rely on others for a sense of security. Such individuals have more negative representations and negative past memories of parents (Mikulincer & Orbach, 1995) and tend to reduce their contact with others. Such responses can be subtle or dramatic, but certainly relevant to psychoanalytic concerns. They are relevant because now, even given some degree of fluidity, we can predict the stability of the attachment system over time, especially when the child demonstrates pathologically insecure or disorganized attachments. This holds both for longitudinal as well as cross-generational predictions (Berlin, Cassidy, Appleyard, 2008; Besser & Pearl, 2005; Main, Hesse, & Kaplan, 2005; Sroufe, Egeland, Carlson, & Collins, 2005; Steele & Steele, 2005; Benoit & Parker, 2004; Hesse, Main, Abrams, & Rifkin, 2003; Fonagy et al., 2002; Lyons-Ruth, 1998; Lyons-Ruth & Jacobvitz, 1998; van IJzendoorn,1995; van Ijzendoorn, Bakermans-Kranenburg, & Marian, 2004; Fonagy, Steele, & Steele, 1991). Thus, if one wishes to understand internalized relationships and their repetitions throughout life, the attachment system and the need for familiarity and safety offers critical information for the analyst. A couple of brief examples of the affect-regulating system may enhance psychodynamic understanding. Here I am discussing instances where infants need to negotiate with mothers who are insensitive or indifferent to their signals. Those mothers who have difficulty modulating their own affect life may over stimulate or under stimulate their youngsters. In the case of the former, for example, it may occur with inappropriate sexual or physical abuse. In the latter case, the primary caregiver, typically the mother may be unable to respond to the child because of her own traumatic past, or of her depression, alcoholism, psychosis, and the like. In such caregiving relationships, the need for an appropriate arousal level for their infant is undermined. Negotiating such problematic interactions the baby is at the mercy or his or her own ineffective self-regulatory needs. Children who are overstimulated may eventually provide a narcissistic solution for themselves. Understimulated children are chronically searching for others as regulators of  their needs which makes them vulnerable to masochistic solutions. Such children would find themselves at the extreme end of pathological attachment relationships, often with some features of disorganized-disoriented attachments. Retrospectively, it is difficult to be clear about the degree to which current behavior reflects an over- or understimulating early experience, due to the interplay of need and defense in subsequent behavior. Thus, for example a wish to tease and to excite in the analytic situation may reflect either a recycled pattern of over stimulation or a defensive masking of the needs of an understimulated self. I think it may be apparent that in addition to recognizing the patient’s affect regulating system, analysts need to know about the way they manage their own level of affect stimulation and its contribution to wish-defense, fantasy, transference-countertransference, and enactments in the analytic relationship. Here I am highlighting the interaction

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of attachment styles between patient and therapist. Researchers (Blatt & Shahar, 2004; Mallinckrodt, Daly, & Wang, 2009) have suggested that differences in attachment styles for each are beneficial in that the therapist offers interventions reflective of his or her attachment style which run counter to the problematic personality style of the patient. Rather than a detriment to treatment it facilitates it. A therapist who has a secure attachment style appears to produce the best outcome with patients. Of course many of us acquire an earned secure attachment style as a result of our hard won analytic understanding. However, we may revert to our more characteristic attachment style when under interpsychic stress (see later discussion of this issue). Nonetheless, as Friedman (2005) warns us,” . . .the analyst [is] partly immune to the patient’s efforts and partly responsive to them. The theory [the analyst employs] is thus not only a magnifying lens; it is a (more or less) interfering agent . . .” (p. 425).

Clinical Case Mr. K was an unusual man to consider intensive treatment. His presentation to the world was florid, showy, and brash with authority and self assurance when discussing issues he cared about. He was a shrewd business man with amazing salesman abilities, sometimes   just circumventing dishonesty. His carriage and girth, serous profanity, appearance of  social success and command hid much of his emotional vulnerability. He wanted others to think of him as powerful and wealthy, a respected, brilliant leader in his community. Whereas he had talents, he could never actually acquire the heights of his fantasy life. His manner included a mixture of arrogant pride, a need to dominate, command, and inform which often alienated others. He possessed, as well, genuine wit and humor, and social gregariousness. He was a driven autodidact, a good raconteur and a man who wished to understand and alter his problematic life and symptoms. The youngest of 13 children, he had endured a childhood of privation, neglect, and physical abuse. He was raised in an impoverished, “filthy,” chaotic household, filled with many older siblings who fought, hit, cursed each other, mercilessly teased, tricked, and denigrated him, and in general, intruded upon one another. There was no household schedule, no emphasis on cleanliness and physical care, no consistent place to sleep, no reliable mealtimes, and no clothes belonging exclusively to him. He vividly remembers a space alongside the kitchen where leftover food and trash would accumulate, until it was overwhelming. Rodents and roaches would roam until someone, often him, would shovel out the garbage. Mr. K.’s mother, an uneducated woman, transported from her Middle Eastern locale, was filled with primitive superstitions, as well as, desperate, grasping, financial needs, mainly to preserve her soul. When she could not cope she became hysterical and resorted to beatings. His father worked long hours, spent time away from the home in the evenings and was essentially unavailable. Although he was clearly smart and capable of good logical thinking with a rapid command of computation, he was a poor, failing student. He left school by the 8th grade. He couldn’t sit still and couldn’t concentrate. He recognized he couldn’t stay in one job for very long, or involve himself with men or women for any length, or tolerate the children he had sired in his brief marriage. He sought treatment because of his panic states which were indecipherable for him. His anxiety immediately escalated to intolerable levels. It interfered with his daily performance. He was unable to concentrate, or work at a task for a period of time. He had

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limited ability to fall and stay asleep, and no capacity to calm himself. The one way he managed was to consume food to a feeling of bursting, which helped him temporarily manage his anxiety. His mother was oppressed by the number of children under her care and she appeared to have little left emotionally for her last-born child. He told me that he could remember tugging at his mother’s skirts as a child, pulling on her sleeve, and pestering her with whiney insistence that sometimes reached tantrum proportions when he needed her attention. He had an early memory of her “sticking bread in his mouth” when he was upset. A later variant of his mother’s reaction to him occurred when he was somewhat older and she couldn’t manage his neediness. Her wish not to be bothered by him led her to “throw money at him.” He would spend it on sweets, and when he could, extend it to treating his friends. His futile attempts to engage her occasionally and his mother’s indifference resulted in a turn from her to his self-reliance at a very young age. It was clear to me that he unconsciously understood he could not depend on, or find solace and security with her. Together they established an avoidant attachment that often spilled over into a disorganized-disoriented one. The avoidant attachment dominated his typical interactions. It was there with his older siblings as well. He was regularly tossed from his bed when they returned home in the evening needing a place to sleep, and he was frequently the target of their attacks and jibes. It is not surprising that he often had recourse to a fantasy of having armed guards surrounding the ceiling of his room who were there to protect him. This fantasy slowly altered to a suspicious concern for all those he met. Such fantasy organization is consistent with the early development of what Bowlby labeled as an internal working model of relationships. Mr. K’s model was dominated by mistrustfulness and guardedness, a belief that he needed to be active in his prevention of assault and abuse. He needed to be independent of others because of their unreliability and potential hurtfulness. It is not surprising that interactions stirred disruptive affect regulation which he could not manage. He would tell me he didn’t need others and was contemptuous and suspicious of most. People were “out to scam him or rip him off.” He was proud of “never letting himself get fucked,” and being a man knowledgeable about the harsh, cruel, dog-eat-dog world, always anticipating the actions of “ball-breakers,” the “cock suckers,” and “exploiters” those searching for “the edge” over him. He told me that even so-called close friendsbusiness partners “scammed him” because “they were out for themselves.” Our talks about his inability to manage his stress and his engaging in a variety of  tasks—alcohol, smoking, gambling, eating, “doing a geographic” (sudden flight), “womanizing” —was never something he understood as related or relevant to his anxiety. He understood engaging in these activities because he was bored. My intervention expressed his difficulties with self-regulation and I explained that he resorted to these activities to calm himself, and when he could, stifle his aloneness. At other times I said “when you feel your anxiety escalating and you feel out of control, you need to distract yourself and this activity (alcohol, gambling, e.g.) helps and it numbs you into not feeling.”(Of course his success at “womanizing,” e.g., gratified his grandiose and narcissistic needs, which we discussed at a later time). During the course of treatment, he eliminated these acts except for overeating, an extremely difficult symptom to eradicate. (Sroufe et al., 2005 describe observations of avoidant mother–infant relationships and they note that, “feeding interactions were not adapted to the pace of the infant” p. 98). He eventually understood that he used an abundance of food and snacks to reduce his stress. Food intake I told him was a way of maintaining a distorted negative connection to his mother. It was the relief she temporarily offered and the way he soothed himself.

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However, it wasn’t an experience he recognized because he ate often in a dissociated state which I labeled for him. When I described food involving a significant relationship to his mother, he found it difficult to understand until he told me that one day looking in the mirror at his corpulent body he believed he looked just like her he “had her body.” It was a shocking experience. Silently I also thought Mr. K’s comment, he “had her body” had dual meaning. He was identified with her and he experienced her sensually. The latter meaning might suggest the beginning of a libidinal relationship with his mother and then with women. His panic states lessened quite early in treatment. It was the initial phase of his utilizing my ability to listen and calm his agitated state. However, I believe the panic states turned into obsessive preoccupations with death and dying. I also linked these experiences to his mother’s preoccupations. She was always insisting on money from him to give to charities so that her giving would protect her from dying. (Now it was his turn to throw money at her when she was insistent.) I commented that even his panic states helped him to be connected to her, to merge with her. I thought of his merger needs as a form of  interactive regulation. It is as though he was saying, “When I am anxious, I share my anxiety with her. I am not alone in it.” He, like her, is constantly worried about death, often turning positive experiences into negative ones by thinking about dying. He first laughed at the idea and then, after a brief pause, told me how he imitates her in many ways, using her exact expressions. When she was anxious or in pain she would say, “Ai, Ai, Ai.” He reports, “I always think I’m imitating her, and I’m mocking her, but I am saying things just like her. What a fuckin’ crazy way to live.” The next phase of his eating issue arose because he sought a nutritional trainer to help him with his weight. Mr. K. described his current behavior with his well-intentioned nutritionist. She was involved in meticulous formulations of programs and advice to control his dietary excesses. She lectured, e-mailed, and called him frequently. He told me he “tunes her out, turns her off” and discards her. In his relationship with me as well he would indicate that although he knows we were talking about something important in a prior session, he typically can’t remember what I was saying. I made a transferential interpretation indicating that both with his trainer and with me he becomes the indifferent deaf mother who disregards the persistent insistent trainer and analyst-child. The eating conflict that he describes within himself, we learn, has some of the earmarks of his earlier relationship with his mother as well. He argues, complains, and battles within himself about eating compulsively until the internal feeling escalates to the point where he must eat. He maintained that he wanted his mother’s attention, acknowledgment, and awareness of him, which he couldn’t accomplish. He substituted what I have described as a dissociated eating state. Through his eating he preserved his battling, insistent, unhappy connection to his mother, solidified by their mutual obesity. Such an experience, from an exclusive drive perspective can be understood as the regressive retreat to an earlier zone of oral gratification and merger. Simultaneously there was an unconscious gratification of his sado-masochism, that is, his hostile identification with the aggressor as well as his self-punitive experience. Whereas the former two may be relevant for this patient, a more comprehensive understanding of all the meanings of his fantasies and interactions would include an attachment perspective. The way I understood it and communicated it in various ways, over time, was that he was reactivating an old repetitive interactive pattern that provided an important though frustrating connection to his mother. When he stuffed himself, he was temporarily offering himself the soothing and security of having a connection. He was not alone, they were together. Even though he insisted that he managed everything by himself (a manner I considered as relying on self-regulation),

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he was maintaining a connection to his mother in his style of eating when he was stressed (interactive regulation). I often focused on the quality of his pathological attachment relationships, his attempts to maintain a controlling, dominating, hurt-filled, and hurtful interaction, which regularly caused serious disruptions in his connections with others. I commented on his constant embattled and embattling ways. He was guarded and suspicious of people wanting to control him, “have an edge over him” and with me as well he appeared to listen and also discard what I say, or to indicate another way I discussed it with him, he listens, often agrees, and then doesn’t act on what he learns. After considerable analytic work about his contempt for others and his privileging of  his independence, occasions arose where he felt close to a woman. They were often young, helpless, and dependent on him, so the experience of feeling intimate with another felt safe. At times he even thought he felt much more. This occurred in his new marriage. He could feel close to his wife and hug her fiercely because of his wish to be joined with her. Gaining some tolerance of his neediness, dependency, and wishes for physical closeness and care from his wife, he also recognized his inability to share her with children. However, he acquiesced to his wife acquiring a dog. He began to explore his relationships more closely when he realized he felt more love toward this dog than he did with people. With surprise, he realized he couldn’t stand to be away from his dog. He thought about the dog all the time. It was so cute and cuddly. He liked to have it rest on his chest and fall asleep that way. When his dog had romped, played, and was tired, he loved the feeling of the dog asleep on his body and the dog’s face close to his own. The dog was so trusting and felt so safe with him that it could fall asleep that way. He enjoyed feeding, washing, grooming, all the pleasures often associated with caring for a newborn and he would go on to train the dog in obedience. He reported that when he was caught up in such concentrated warm and nurturing feelings with his dog, he would get sexually aroused. He described this as similar to reactions he used to have when pursuing young vulnerable women. For example, his occasional tender feelings of  friendship and care for a much younger troubled female adolescent suddenly turned sexual. He commented as well that when he hugged these women, especially his new, young, wife, he wished to be so close that he feared he would squeeze them and her too hard. With his dog, he was aware of his fear of losing this precious animal and he was disturbed by intrusive thoughts of seriously hurting the dog, for example, of tossing it off  a balcony ledge. There is much that could be addressed in this vignette that arose out of analytic work. However, initially I focused and discussed his neediness and wishes for intense closeness which would fuse the two of them. At another time I stressed that when his wishes for closeness became intense, his need for physical contact and soothing were transformed into hostile and destructive ideas. In other words, his safety was challenged in intimacy and his avoidant attachment resurfaced. His wish to be overly close was followed by his more pronounced need for distance and security, and thus his negative, hostile ideas were engaged. Interactive regulation was replaced by the more familiar self-regulation. This vignette reflects as well his unconscious identification with his helpless dog-baby an idea that was more accessible to him. I recognized as well that there is also a growing capacity for warmth and tenderness, even love—a new experience for him—but less available when humans were involved. I also reflected with him on his unconscious contempt and hatred toward such helplessness; as well as his wishes for power, domination, control, and potential destruction, which were expressed in his form of caregiving. Over time he recognized that he had contempt for his needy dependent children that he had sired during

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his brief early marriage. Understanding brought greater consideration of them and genuine helpfulness on his part. He told me that he feels bad about how he was as a father and works at making amends. However, I wish to focus on his description of the shift from compelling affect to sexual excitation. He described feeling filled with tension as a result of such strong feelings for his dog, similar to his past experiences with young exploitable females. Such powerful emotions would lead to sexual desire. If he was then able to consummate a sexual experience, the excitement and tension was alleviated and he felt great relief. I believe this brief example illustrates Freud’s (1905/1961) and later George Klein’s (1976) notion of vital needs that can be expressed through sexual modes. The patient’s wish for vehemently felt physical attachment rapidly escalated to peak intensity and he could not tolerate such heightened anxiety states. Sexuality, according to him, felt liberating and ended his tension. He described an unmodulated affect state that could be acknowledged as suffused with his needs for tenderness caring, holding, and stroking. He gradually understood that such experiences could only be accepted as sexual. In this latter form he felt powerful, masculine, autonomous, and in control. I suggest that the zone of  phallic sexuality functioned as a channel of relief, masking a host of unmet needs associated with impoverished affect regulation. It should also be noted that his ability to trust and confide in me suggested his increasing ability to shift from self regulation, even with his conflicted feelings of  dependency, to relying on interactive regulation. He told me that my office was the only place in the world he felt secure. He frequently remarked that therapy had saved his life. “If not for therapy I would be in prison or dead.” He had dramatically altered many aspects of both his personal and work life. For example, he told me with humility tinged with pride, how he learned that people respected him in his field as an honest, reliable, and trustworthy person. People said, “He could call upon them for any merchandise he needed. They would have no hesitation, nor worry about the payment. He was fair.” In a business he considered wracked with corruption, he has become unblemished and honorable.

Discussion Does an attachment perspective provide more than, for example, an ego psychological approach emphasizing defense analysis? I maintain that the underlying theories are different and therefore have distinct therapeutic implications. The latter is a wish-defense theory where affects signal the struggle over conflictual wishes. The affect is specifically linked to unacceptable unconscious wishes and thus the need for defense. When affects break through and anxiety is directly experienced the defenses are inadequate to handle it and primitive wishes emerge into consciousness. In an ego psychological point of view, unconscious seductive behavior toward the analyst may be possibly linked to an underlying Oedipal wish, or a wish for power and domination, or to thwart a destructive wish toward the analyst, and so forth. 5

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We might also compare the attachment system with Luborsky’s (Luborsky & Luborsky, 1993) Core Conflictual Relationship Theme (CCRT) as both are about key relationships and their difficulties. However, Luborsky’s work, as well, is about wishes—one set of unconscious wishes conflicting with another set; or wishes in conflict with the unconscious anticipated response of others and the experience of this for the individual.

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By contrast, the attachment system has affect regulation as its major motivation. Affect regulation, is significant in all infant–mother interactions; it is a powerful issue for patients who demonstrate an avoidant attachment. The attention to very early and consistent emotional misattunements between mothers and infants and its powerful shaping affects on subsequent personality organization offer a different development trajectory than the one from traditional theory. Rather than a psychosexual theory, the attachment system is a prosocial theory, with a focus on empathy, concern, and care that caregivers provide for their infants and the serious maladaptive consequences when such sensitivities are unavailable. Consistent strain and severe trauma affecting the development of an avoidant attachment, contribute to sculpting the architecture of the mind, brain, and subsequent behavior (Haggerty, Siefert, & Weinberger, 2010; Le Doux, 1996). An understanding that avoidantly attached patients restrict or suppress their emotions, led to my addressing his lack of emotions when discussing features of his history or his current relationships. There was a contrast between his indifferent reporting and my experience of his painful narrative. This gap helped me to increase his awareness of his vulnerabilities. A further characteristic was his inability to consider the elements of  emotional events that prompted difficulties with others. He never took note of the effect of his own behavior on others. Righteous indignation about their responses was his typical reaction. His subsequent memories of difficult interpersonal events were invariably one-sided, excluding the thoughts and feelings of others (an inability to mentalize in Fonagy’s terms, 1999). When such thinking and behavior remains unaddressed, an inflexible avoidant interaction continued. The regular reoccurrence of an understimulated or overstimulated state or their oscillations cause serious emotional perturbations. This was true for Mr. K. When the patient needs help to regulate an understimulated self, it is because he can feel deadened and meaningless. This state is different than depression. The patient does not feel depressed, but rather empty, not alive, sometimes expressed as robotic. I maintain this is a unique feeling state. At its extreme, there is a frozen quality to Mr. K., which is related to a disorganized attachment; here there is a breakdown of organized attachment strategies. A basic biological need for the other is seen as a major threat instead of a source of protection and comfort. When Mr. K. experienced overstimulation he reported being so overwhelmed that he needed “to bring himself down to earth.” Self criticality and depression would often be induced by him to deal with “leaving the ground and floating dangerously in the stratosphere.” It can be experienced as a potential loss of reality, or going crazy, and thus the need for defense. It is the reverse of feeling depressive affect and then the need for stimulation (sports activity, shopping) to obviate the depression. His serious neglect early in his life (validated by older family members) often left him understimulated. When understimulated states reoccurred, it later led to his “clowning around,” disordered conduct, outrageous behavior, or overly munificent actions so that others would acknowledge and appreciate him. However, he invariably felt others failed or disappointed him and he would scornfully withdraw. Over the course of development, unconscious fantasies (“I am going crazy”) also got linked to arousing instability, but initially reactions are yoked to the child’s inability to regulate his emotional state. These formulations may exist along with unconscious Oedipal concerns and when appropriate, would need analytic attention as well. There is another important difference when an attachment perspective is considered. Avoidant attachments need to be understood as coping mechanisms. They are adaptive

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strategies for dealing with early and long-standing lacks of emotional closeness, as well as experiences of rejection. In Mr. K’s case, it was a negative, resistant form of relating, but relating nevertheless. It had offered him an experience of connection and safety as a child and continued to maintain a sense of security for him. That is, assuring his mother of his lack of neediness and his self-sufficiency allowed her to sustain a satisfying connection and provided the child with an unrealistic but important sense of competence and independence, preserving their unconscious tie. What was initially a defense for the child becomes an adaptation. Had I understood his coping style as primarily defensive, interpretations would have had no meaning for him. Mr. K. would not be able to understand his attachment as a defense masking wishes for contact. (He didn’t need people in his life; they left him disappointed and cheated. Being alone was better than being with stupid others.) It was a firmly fixed, long-standing, effective stratagem and one without conflict.6 When the analyst sees avoidant attachment primarily as a defense, it can lead to frustration and antagonism because of the patient’s inability to alter his form of emotional connections. Psychodynamic therapists are more likely to be sensitive to threats of  separation (Schauenburg et al., 2010) thereby potentially increasing their negative reaction to an avoidant attachment patient. The therapeutic alliance is at cross purposes. The patient wants to remain emotionally uninvolved and the therapist works at establishing trust and an emotional bond, a salient feature of effective outcome (Wampold, 2001). The analyst needs to tolerate considerable indifference and lack of appreciation from the patient, but at the same time to remain emotionally engaged even when the patient is unengaged and denigrating. An interesting finding about the transference-countertransference interaction derived from transcripts of therapy sessions with avoidant patients is that therapists often become too rational and intellectual with these patients, offering cognitive interpretations rather than reflecting on their patients’ emotions, vulnerabilities, and concerns (Mikulincer, Shaver, Cassidy & Berant, 2009). Thinking from an attachment perspective may help the analyst deal with his or her countertransference, that is, recognition of the nature of one’s own attachment style when under duress. An inclination toward an anxious-ambivalent attachment, when there is negative interpersonal pressure, may invoke increased caregiving and/or problematic self-disclosures, for example, as a way to augment the analyst’s needed acceptance and fear of loss. A tendency toward an avoidant attachment when under interactive stress, with a more anxious-preoccupied patient can induce strong negative feelings toward such neediness (Mohr, Gelso, & Hill, 2005). With an avoidant-attachment style patient, the analyst may unconsciously circumvent dealing with either less conscious emotional content or raw affect-laden material in the patient. It may lead to a tendency to mute and/or disown and distance one’s own emotions in relation to strong, especially negatively directed, feelings in the patient. In such instances, the retraumatization of the patient may occur.

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One study reported that avoidant individuals are actually able to reduce physiological arousal . . . “rather than merely masking distress or deny it in self reports” (Fraley & Shaver, 1997, reported in Mallinckrodt, Daly, & Wong, 2009) However, another finding demonstrates that when pronounced stress-relevant cognitive material was offered, avoidant individuals did show physiological arousal levels (Mikulincer, Shaver, Cassidy, & Berant, 2009). However, it is not yet clear if  this translates into unconscious psychic stress. For example, is heightened skin resistance, one indicator of physiological arousal, experienced psychically? Nonetheless, it may reflect long-term dissociative experiences for those with an avoidant attachment.

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Returning to the patient, the long, slow course of an enduring, caring process of  treatment with tolerance and understanding of Mr. K’s style of relating tempered his avoidant attachment enough so that some safer risks became possible, both with his wife and in our relationship. An unspoken background feature of the transference was his experience of me as reflecting qualities his mother lacked. Thus a silent fantasied idealization of me became internalized and his capacity to change was activated. Sometimes he would chastise me for my ineffectiveness, but he always showed up for his appointments, and always on time. In addition to my ineptitude, there was considerable spontaneous playfulness between us, and I could enjoy the twists of his outrageous communications and his turns of mind. What was impressive was his struggles to acknowledge his isolated life and his restricted need for others, his recognitions of his limitations when compared to his florid omnipotent fantasies of wealth, power, and achievement, his serious disappointments in his offspring, as well as his guilt and later helpfulness as a parent, his capacity to recognize his love, care, and genuine pleasure with his wife, his hard-won appreciation that his life was finite, and his acceptance of what I recognized as his many positive attributes.

Summary Tracking the changes in Mr. K’s attachment relationships suggests increased secure experiences as well as his retreats to old patterns. The alteration of his avoidant attachment is most clearly seen in our relationship. Increasingly, Mr. K. felt safe to discuss difficult emotional issues and to find a degree of calm with me. Sometimes it was just my quiet, but actively involved listening stance that relaxed him and made his emotions manageable. Our relationship eventually reached a durable consistent pattern of participatory interaction that was uniformly helpful. His avoidant attachment with me appeared transformed. There was some degree of generalization with people close to him whom he really cared about. This was especially true of a solidified and trusting relationship with his wife and it was there as well with his offspring. His children were typically beset by repeated difficulties. He remained caring and concerned and could offer helpful parental advice. An extension of his changed attachment also occurred with people who worked for him. He was dedicated to them, tolerant of their mishaps and errors, as well as considerate and generous. He kept them on his payroll even in difficult financial times. (Being in the dominant managerial position with his young family and workers certainly helped to minimize an avoidant attachment). Dramatic changes took place in his employment. Initially, he rapidly left jobs and searched for the next “big” opportunity. He could not remain long in one place or position and this was true even when it was his own establishment. Regularly bored, frustrated, and disconcerted, he would abandon work. Our analytic consideration of this issue led him to recognize where his capacities lay and he learned to struggle and remain with his chosen occupation. He achieved his greatest success tolerating his labile emotional states in his work life. Even difficult interpersonal transactions were handled more appropriately without his necessarily becoming overstimulated to the point of considering destructive and self-destructive initiatives. His avoidant attachment though could emerge when he reexperienced internal states of  emptiness, and meaninglessness, an understimulated state. Finding himself “unjustly” maligned by an important business person in his life could induce this return. Often, it was not a close relationship; rather, it was a symbolic loss. Yet, he maintained he was

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indifferent to the loss; he planned to terminate any further connection. However, he became preoccupied with the injustice, preventing and interrupting his sleep, and inducing an agitated state which he had difficulty modulating. Financial straits, lack of business opportunities, and especially idleness could also throw him back into his experience of a barren life. Then he is likely to find others as incompetent, stupid, and worthless, and he returns to his shunning of them, once again asserting his avoidant attachment stance. However, these setbacks were briefer. This too indicated progress.

Conclusion Attachment theory and its application can prove to be an effective therapeutic tool. There is a focus within the analyst on the quality of the initial and subsequent parent-infant relationship. When there is evidence of an established avoidant attachment, it highlights the problems for the child, and later, the adult in managing affect regulation. The analyst and patient need to identify and focus on these maladaptive emotional states because patients are unable to manage them. At the same time, the patient’s relationships are skewed in the direction of self-sufficiency and dismissiveness of others. New exchanges between patient and analyst are assimilated into the patient’s characteristic mental model of negative interactions. Mistrust and paranoid preoccupations with the malicious intent of  others, hamper a connection of mutual trust and care. The analyst’s appreciation of a long-standing coping mechanism that is resistant to alteration is useful in maintaining his or her own equilibrium. Understanding the patient’s avoidant attachment as an adaptive stratagem rather than a primary defense can reduce frustration and stress in the analyst. It is not a question of masking distress because of conflict over the need for a connection; the patient does not experience such a need. The analytic process must of necessity be a long slow one with the analyst maintaining an emotional commitment of care and concern in the face of derogation and rejection.

References Belsky, J. (2006). Determinants and consequences of infant-parent attachment. In L. Balter & C. S. Tamis-LeMonda, C. S. (Eds.), Child psychology: A handbook of contemporary issues (2nd ed.; pp. 53–77). New York: Psychology Press. Benoit, D., & Parker, K. C. (1994). Stability and transmission of attachment across three generations. Child Development, 65, 1444–1456. Berlin, L. J., Cassidy, J., & Appleyard, K. (2008). The influence of early attachments on other relationships. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (2nd ed.; pp. 333–347). New York: Guilford Press Besser, A., & Priel, B. (2005). The apple does not fall far from the tree: Attachment styles and personality vulnerabilities in three generations of women. Society for Personality and Social Psychology, 31, 1052–1073. Blatt, S. J., & Shahar, G. (2004). Psychoanalysis-with whom, for what and how? Comparisons with psychotherapy. Journal of the American Psychoanalytic Association, 52, 393–447. Blatt, S. J., & Luyton, P. (in press). Contemporary directions in psychopathology. Toward DSM-V,   ICD-11, and beyond. T. Millon, P. Krueger, & E. Simonsen (Eds.) (pp. 1–71). New York: Guilford Press. Brettherton, I., Lambert, J., & Golby, B. (2005). Fathers of preschool children as seen by themselves and their wives: Accounts of attachment socialization, and companionship. Attachment and   Human Development, 7, 229–251. Cortina, M. (2003). Defensive processes, emotions and internal working models: A perspective from

308

SILVERMAN

attachment theory and contemporary models of the mind. In M. Cortina. & M. Marrone (Eds.),  Attachment theory and the psychoanalytic practice. (pp. 271–306.) London: Whurr Publishers. Diamond, D., Clarkin, J., Levine, H., Levy, K., Foelsch, P., & Yeomans, F. (1999). Borderline conditions and attachment: A preliminary report. Psychoanalytic Inquiry, 19, 831–884. Feldman, M. (2009, March). Adjusting the distance: Coping with agoraphobic, claustrophobic and   paranoid anxieties within the session. Paper presented at the Rita Frankiel Memorial Presentation, NYFS, New York City. Fonagy, P. (1999). Psychoanaytic theory from the viewpoint of attachment theory and research. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment  (pp. 595–624). New York: Guilford Press. Fonagy, P. (2001). Attachment theory and psychoanalysis. New York: Other Press. Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. New York: Other Press. Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Matoon, G., . . . Gerber, A. (1996). The relation of attachment status, psychiatric classification and response to psychotherapy. Journal of  Consulting and Clinical Psychology, 64, 22–31. Fonagy, P., Steele, H., & Steele, M. (1991). Maternal representations of attachment during pregnancy predict the organization of infant-mother attachment at one year of age. Child   Development, 62, 891–905. Fraley, R. C., & Shaver, P. R. (1997). Adult attachment and the suppression of unwanted thoughts.  Journal of Personality and Social Psychology, 73, 1080–1091. Freud, S. (1961). Three essays on the theory of sexuality. In J. Strachey (Ed. & Trans.), The standard  edition of the complete psychological works of Sigmund Freud, (Vol. 7, pp. 135–143). London: Hogarth Press. (Original work published 1905) Friedman, L. (2005). Psychoanalytic treatment: Thick soup or thin gruel? Psychoanalytic Inquiry, 25, 418–439. Haggerty, G. D., Siefert, C. J., & Weinberger, J. (2009). Examining the relationship between current attachment status and freely recalled autobiographical memories of childhood. Psychoanalytic Psychology, 27, 27–41. Hesse, E., & Main, M. (2000). Disorganized infant, child, and adult attachment. Journal of the  American Psychoanalytic Association, 48, 1097–1127. Hesse, E., Main, M., Abrams, K. Y., & Rifkin, A. (2003). Unresolved states regarding loss or abuse can have “second generation” effects: Disorganized role-inversion and frightening ideation in the offspring of traumatized nonmaltreating parents. In S. M. F. Solomon, & D. J. Siegel (Eds.),  Healing trauma: Attachment, mind, body, brain. (pp. 57–106). New York: Norton Johansson, P., Hogland, P., Ulberg, R., Bogwals, K.-P., Amlo, S., Marble, A., Cosgrove Sjaastad, M., Sorbye, O., . . . Heyerdahl, O. (in press). The mediating role of insight for longterm improvements in psychodynamic therapy. Journal of Consulting and Clinical Psychology. Jurist, E. L., Slade, A., & Bergner, S. (2008). Mind to mind. Infant research, neuroscience, and   psychoanalysis. New York: Other Press. Kirchmann, H., Mestel, R., Schreiber-Willnow, K., Mattke, D., Seidler, K.-P., Daudert, E., . . . Strauss, B. (2009). Associations among attachment characteristics, patients’ assessment of  therapeutic factors, and treatment outcome following inpatient psychodynamic group therapy. Psychotherapy Research, 19, 234–248. Klein, G. (1976). Psychoanalytic theory. New York: International Universities Press. Kohut, H. (1977). The restoration of the self. New York: International Universities Press. Lawson, D. M., & Brossart, D. F. (2009). Attachment, interpersonal problems, and treatment outcome in group therapy for interpersonal violence. Psychology of Men & Masculinity, 10, 288–301. Le Doux, J. (1996). The emotional brain. New York: Touchstone. Luborsky, L., & Luborsky, E. (1993). The era of Measures of transference: The CCRT and other measures. Journal of the American Psychoanalytic Association, 41S, 329–351.

A CLINICAL CASE OF AN AVOIDANT ATTACHMENT

309

Lyons-Ruth, K. (1998). The interface between attachment and intersubjectivity: Perspective from the longitudinal study of disorganized attachment. Psychoanalytic Inquiry, 19, 196–616. Lyons-Ruth, K., & Jacobvitz, D. (1998). Attachment disorganization: Genetic factors, parenting contexts, and developmental transformation from infancy to adulthood . In J. Cassidy, P. Shaver (Eds)., Handbook of attachment: Theory, research, and clinical applications (2nd ed.), (pp. 666–697). New York, NY. Guilford Press. Main, M., Hesse, E., & Kaplan, N. (2005). Predictability of attachment behavior and representation processes at 1, 6, and 19 years of age: The Berkeley Longitudinal Study. In K. E. Grossmann, K. Grossmann, & E. Waters (Eds.), Attachment from infancy to adulthood the major longitudinal studies (pp. 245–304). New York: Guilford Press. Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. In I. Bretherton & E. Waters. (Eds.), Growing points of attachment  theory and research. Monographs of the society for research in child development  (Vol. 50 [1–2], serial no. 209, pp. 66–104). Chicago: University of Chicago Press. Main, M. (2000). The Organized Categories of Infant, Child, and Adult Attachment. Journal of the  American Psychoanalytic. Assn., 48, 1055–1095. Mallinckrodt, B., Daly, K., & Wang, C. C. D. C. (2009). An attachment approach to adult psychotherapy. In J. H. Obegi & E. Berant (Eds.), Attachment theory and research in clinical work with adults (pp. 234–268). New York: Guilford Press. Mikulincer, M., & Orbach. L. (1995). Attachment styles and repressive defensiveness: The accessibility and architecture of affective memories. Journal of Personality and Social Psychology, 68, 917–925. Mikulincer, M., Shaver, P. R., Cassidy, J., & Berant, E. (2009). Attachment: Related defensive processes. In J. H. Obegi & E. Berant (Eds.), Attachment theory and research in clinical work  with adults (pp. 293–327). New York: Guilford Press. 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. Muller, R. T. (2009). Trauma and dismissing (avoidant attachment): Intervention strategies in individual psychotherapy. Psychotherapy, Research, Practice, Training, 46, 68–81. Muller, R. T., & Rosenkranz, S. E. (2009). Attachment and treatment response among adults in inpatient treatment for postraumatic stress disorder. Psychotherapy: Theory, Research, Practice, Training, 46, 82–96. Obegi, J. H., & Berant, E. (2009). Attachment theory and research in clinical work with adults. New York: Guilford Press. Piper, W. E., Azim, H. F. A., Joyce, A. S., & McCallum, M. (1991). Transference interpretations, therapeutic alliance, and outcome in short term individual psychotherapy. Archives of General Psychiatry, 48, 946–953. Sable, P. (1997). Disorders of adult attachment. Psychotherapy, 34, 286–296. Schauenburg, H., Buchheim, A., Beckh, K., Nolte, T., Brenk-Franz, K., Leichsenring, F., Strack, M., & Dinger, U. (2010). Psychodynamically oriented therapists’ attachment representations on outcome and alliance in inpatient psychotherapy. Psychotherapy Research, 20, 193–202. Silverman, D. K. (1986). A multi-model approach: Looking at clinical data from three theoretical perspectives. Psychoanalytic Psychology, 3, 121–132. Silverman, D. K. (2010). Our sexy brain, our compelling environment: Interactionism in female development. Psychoanalytic Review, 97, 1–19. Slade, A. (1999). Attachment theory and research: Implications for the theory and practice of  individual psychotherapy with adults. In J. Cassidy & P. R. Shaver (Eds.), The handbook of  attachment theory and research. (pp. 575–594). New York: Guilford Press. Slade, A. (2000). The development and organization of attachment: Implications for psychoanalysis.  Journal of the American Psychoanalytic Association, 48, 1147–1174. Slochower, J. (1996). Holding and psychoanalysis: A relational perspective. Hillsdale, NJ: Analytic Press.

310

SILVERMAN

Spangler, G., & Grossman, G. (1993). Behavior organization in securely and insecurely attached infants. Child Development, 63, 1439–1450. Sroufe, L. A., Egeland, B., Carlson, E. A., & Collins, W. A. (2005). The development of the person. The Minnesota Study of Risk and Adaptation from Birth to Adulthood. In K. E. Grossmann, K. Gorssmann, & E. Waters (Eds.), Attachment from infancy to adulthood: The major longitudinal studies (pp. 46–70). New York: Guilford Press. Sroufe, L. A., & Waters, E. (1977). Heart rate as a convergent measure in clinical and development research. Merrill-Palmer Quarterly, 23, 3–27. Stark, M. (1997). Welcome and opening remarks. Presented at conference on “Developmental Process and the Enigma of Change in Psychodynamic Therapy.” Boston, MA, March. Steele, H., & Steele, M. (2005). Understanding and resolving emotional conflict: Findings from the London Parent-Child Project. In K. E. Grossmann, K. Grossmann, & E. Waters (Eds.), Attachment from infancy to adulthood: The major longitudinal studies (pp. 137–164). New York: Guilford Press. Stern, D. (1997). Developmental process and the reordering of the intersubjective environment in treatment. Presented at conference on “Developmental Process and thd Enigma of Change in Psychodynamic Therapy.” Boston, MA, March. Stern, D. N. (1998). The process of therapeutic change involving implicit knowledge: Some observations for adult psychotherapy. Infant Mental Health Journal, 19, 300–309. Trevarthon, C. (1980). The foundations of intersubjectivity: The development of interpersonal and cooperative understanding in infants. In D. Olson (Ed.), The social foundations of language and  thought: Essays in honor of J. S. Bruner  (pp. 316–342). New York: Norton. Tronick, E. Z. (1997). Relevant video vignettes from infant observational research. Video and paper presented at conference on “Developmental Process and the Enigma of Change in Psychotherapy.” Boston MA, March. Tronick, E. Z. (2007a). Dyadically expanded states of consciousness. In The neurobehavioral and  social-emotional development of infants and children. New York: Norton. Tronick, E. Z. (2007b). The neurobehavioral and social-emotional development of infants and  children. New York: Norton. van Ijzendoorn, M. H., Bakemans-Kranenburg, M. J., & Marion, J. (2004). In G. Bremner, & A. Slater (Eds.), Maternal sensitivity and infant temperament in the formation of attachment. In Theories of infant development. (pp. 233–257). Malden: Blackwell Publishing. van IJzendorm, M. (1995). Adult attachment representations, parental responsiveness, and infant attachment: A meta-analysis on the predictive validity of the adult attachment interview. Psychological Bulletin, 337, 387–403. Wallin, D. J. (2007). Attachment in psychotherapy. New York: Guilford Press. Wampold, B. E. (2001). The great psychotherapy debate. Models, methods, and findings. Mahwah: NJ: Lawrence Erlbaum Assoc. Weiner, S. (2003). The significance of the exploration of the patient’s attachment history for psychoanalytic psychotherapy. In M. Cortina & M. Marrone (Eds.), Attachment theory and the   psychoanalytic practice (pp. 92–106). London: Whurr Publishers.