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Hedgehogs in therapy. Empathy andinsecure attachment in emotion-focused therapyMarijke Baljon a & Grieteke Pool ba Clinical Psychologist-Psychotherapist , Groningen , TheNetherlandsb Department of Health Psychology, RUG/UMCG , Groningen , TheNetherlandsPublished online: 15 Jul 2013.

To cite this article: Marijke Baljon & Grieteke Pool (2013) Hedgehogs in therapy. Empathy andinsecure attachment in emotion-focused therapy, Person-Centered & Experiential Psychotherapies,12:2, 112-125, DOI: 10.1080/14779757.2013.804652

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Hedgehogs in therapy. Empathy and insecure attachment inemotion-focused therapy

Marijke Baljona* and Grieteke Poolb

aClinical Psychologist-Psychotherapist, Groningen, The Netherlands; bDepartment of HealthPsychology, RUG/UMCG, Groningen, The Netherlands

(Received 17 October 2012; final version received 23 April 2013)

Not all clients respond positively to an empathic, validating relationship. They with-draw from contact, because emotional intimacy frightens them. This can be explainedby insecure attachment, which can result in fragile experience. Emotional events arethen experienced with extreme vehemence, or only for a very short time. Thus, we cancome to understand why some clients respond negatively to intimacy and sympathy.This can help us to stimulate a deeper form of empathy, and can give us the patience tolet clients develop trust at their own tempo. In this article, we describe markers of threetypes of insecure attachment, inspired by a narrative-informed approach to emotion-focused therapy (EFT). For each type, we formulate a specific kind of psychother-apeutic intervention. By approaching the client in a cautious and sometimes ratherrational manner, the client can gradually discover that it is safe to experience and sharevulnerability. This approach is illustrated with clinical cases.

Keywords: empathy; insecure attachment; emotion-focused; narrative approach

Niet alle cliënten reageren positief op een empathische, validerende relatie. Ze trekkenzich terug uit het contact omdat intimiteit hen angstig maakt. Dit kan verklaard wordenuit onveilige hechting die kan leiden tot een fragiele beleving. Emotionele ervaringenworden dan zeer heftig beleefd of kunnen maar kort worden vast gehouden. Vandaaruit kunnen we begrijpen waarom sommige cliënten negatief reageren op intimiteiten sympathie. Dit inzicht kan een diepere vorm van empathie bevorderen en onsgeduld schenken om de cliënt in zijn eigen tempo vertrouwen te laten ontwikkelen.In dit artikel beschrijven we processignalen voor drie vormen van onveilige hechting,geïnspireerd door de narratieve variant van de emotiegerichte therapie (EFT). Voor elkvan deze hechtingsstijlen beschrijven we specifieke psychotherapeutische interventies.Een behoedzame, deels rationele benadering van deze innerlijke belevingen kan helpenom de cliënt geleidelijk aan te laten ervaren dat het veilig kan zijn om kwetsbaarheid tebeleven en te delen. De benadering wordt geïllustreerd door klinische vignetten.

Nicht alle Klienten reagieren auf eine empathische, validierende Beziehung positiv. Sieentziehen sich dem Kontakt, weil emotionale Intimität sie ängstigt. Dies kann man mitunsicherer Bindung erklären, die in einer fragilen Erfahrung resultieren kann.Emotionale Ereignisse werden dann mit grosser Intensität empfunden oder nur sehrkurz. So können wir allmählich verstehen, warum einige Klienten auf Intimität undMitgefühl negativ reagieren. Dies kann helfen, eine tiefere Form von Empathie zuwecken und Geduld zu haben, damit die Klienten das Vertrauen im eigenen Tempoentwickeln. In diesem Artikel beschreiben wir Marker für drei Arten von unsicherer

*Corresponding author. Email: therapie@marijkebaljon.nl

Person-Centered & Experiential Psychotherapies, 2013Vol. 12, No. 2, 112–125, http://dx.doi.org/10.1080/14779757.2013.804652

© 2013 World Association for Person-Centered & Experiential Psychotherapy & Counseling

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Bindung, angeregt durch einen narrativ-informierten Ansatz zu Emotions-fokussierterTherapie (EFT). Für jede Art formulieren wir eine spezifische Form psychotherapeu-tischer Intervention. Indem wir uns dem Klienten in einer vorsichtigen und manchmaleher rationalen Art nähern, kann der Klient allmählich entdecken, dass es ungefährlichist, Verletzlichkeit zu durchleben und das mit anderen zu teilen. Dieser Ansatz wird mitFallbeispielen illustriert.

No todos los consultantes responden positivamente a una relación empática validante.Algunos rehuyen el contacto, porque les asusta la intimidad emocional. Esto puedeexplicarse por un apego inseguro/débil que puede resultar en una experiencia frágil. Enesos casos los eventos emocionales se experiencian con extrema vehemencia, o sólopor un tiempo muy corto. Así podemos llegar a entender por qué algunos consultantesresponden negativamente a la intimidad y simpatía. Esto nos puede ayudar a estimularuna forma más profunda de empatía y nos puede dar la paciencia necesaria para queconsultantes desarrollen confianza en su propio tiempo. En este escrito, inspirado porun enfoque terapéutico enfocado en la emoción, e informado de narrativa, describimostres tipos de marcadores de apego inseguro. Para cada tipo formulamos una formaespecífica de intervención psicoterapéutica. Al abordar al consultante de maneraprudente y a veces algo racional, el consultante puede descubrir poco a poco que esseguro experienciar y compartir la vulnerabilidad. Ejemplificamos este enfoque concasos clínicos.

Tous les clients ne réagissent pas de manière positive à une relation empathique etvalidante. Ils se retirent du contact, car l’intimité émotionnelle leur fait peur. Ceci peutêtre expliqué par un attachement insecure qui favorise une expérience fragile. Lesévènement émotionnels sont alors expérimentés avec une véhemence extrême, ouseulement pour un temps très court. Cela nous permet de comprendre pourquoi certainsclients réagissent négativement à l’empathie et à la compassion. Cela peut nous aider àstimuler une forme d’empathie plus profonde, et peut favoriser chez nous la patiencede laisser la confiance se développer au rythme de ces clients. Dans cet article nousdécrivons des marqueurs de 3 types d’attachement insecure, inspirés par une approchede la thérapie focalisée sur l’émotion (TFE) utilisant la narration. Pour chaque type,nous formulons un type d’intervention spécifique. En nous approchant du client demanière précautionneuse et quelques fois de manière rationnelle, le client peut, petit àpetit, découvrir qu’il peut faire l’expérience de la vulnérabilité et la partager ensécurité. Cette approche est illustrée de cas cliniques.

Nem todos os clientes reagem de forma positiva a uma relação empática e significativa.Alguns alheiam-se do contacto porque a intimidade emocional os assusta. Tal pode serexplicado por um apego inseguro que pode resultar numa experiência de fragilidade.Os acontecimentos de natureza emocional passam a ser vivenciados com uma intensi-dade extrema ou apenas por um curto período de tempo. Assim sendo, conseguimosperceber porque é que alguns clientes reagem de forma negativa à intimidade e àcompaixão. Tal pode ajudar-nos a estimular uma forma mais profunda de empatia edar-nos a paciência para permitir aos clientes desenvolverem confiança ao seu próprioritmo. Neste artigo descrevemos os marcadores de três tipos de apego inseguro,inspirados numa abordagem narrativo-informada da terapia focada na emoção (TFE).Para cada um deles propomos uma intervenção terapêutica específica. Ao abordarmoso cliente de forma cautelosa e, por vezes, racional, ele pode descobrir gradualmenteque é seguro experienciar e partilhar a vulnerabilidade. Esta abordagem é ilustrada porcasos clínicos.

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Person-Centered & Experiential Psychotherapies 113

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Introduction

Not all clients respond favorably to explicit empathic expressions. Bohart et al. (2002) citeevidence found by Beutler, Crago, and Arizmendi (1986, p. 279) that suggests that“patients who are highly sensitive, suspicious, poorly motivated, and reactive againstauthority perform relatively poorly with therapists who are particularly empathic, involvedand accepting.” Mohr and Woodhouse (2001) found that some clients prefer businesslikerather than warm, empathic therapists. Working with clients who have been traumatizedearly in their development, we notice that they can be so frightened of emotional intimacythat they cannot bear empathy and acceptance from their therapist. This means thatRogers’ (1959) sixth condition of therapeutic personality change is at stake (Baljon,2011). Apparently, we have to be careful in expressing our empathy and understanding,if we wish to create a safe connection with such clients. At first glance, this seems to runcounter to the client-centered principle that psychotherapy should start with forming andfacilitating a safe and warm relationship. This is not the case. The point is that we have tomonitor the degree of closeness to the ability of the client to tolerate it. This is inagreement with the communicative version of the 6th condition: “That the communicationto the client of the therapist’s empathic understanding and unconditional positive regardis, at least to a minimal degree, achieved” (Rogers, 1959, p. 213).

Explanations for this phenomenon can be found in attachment theory. One of attach-ment theory’s key premises is that internal working models guide expectations, appraisals,feeling, and behaviors in subsequent relationships, throughout childhood, and into adoles-cence and adulthood. Not understanding the different attachment styles and internalworking models of clients might mean that clients do not get the “appropriate” meetingfrom a therapist.

To assess these internal working models in children their behavior is observed after abrief separation from their mother. Instruments that are developed to assess the state ofmind of adults with respect to attachment are attachment interviews and self-reportmeasures. Within psychotherapy, we can look for markers that are an indication for theattachment style. We find these in the way the client tells her story, both in the structure ofthe story (narrative) and in the way the client speaks (vocal style). Finally, we can adjustinterventions to attachment style. For an overview see Table 1.

Since the 1980s, there has been a lively discussion among client-centered therapists in theNetherlands about how to adopt their approach to differences between clients. Swildens(1988/1997, 1996) did pioneering work, showing how clients with different psychiatricdiagnoses each require a specific client-centered approach. Many Dutch authors havefollowed his lead, writing about differentiated application of the client-centered principlesfor various target groups (for instance: Baljon, 2011; Coffeng, 2005; Takens & Lietaer, 2004;Moolen van der, 2002). Starting from this rich tradition, we will explore in this contributionthe influence of client insecure attachment styles on the therapeutic relationship.

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This paper has two parts. The first part presents theory on attachment and psychotherapy.At the end of this part we relate attachment to markers from narrative informed emotion-focused therapy. In the second part we discuss emotion-focused therapy, adjusted to insecureattachment styles. This is illustrated by clinical case material.

Attachment

Theory

Bowlby (1969, 1973) developed the basic tenets of attachment theory in the 1950s of thelast century. From an ethological perspective, reliance on a caregiver is critical to survival.When the infant experiences threat, moving toward the caregiver maximizes thelikelihood of survival. Secure attachment develops when caregivers respond sensitivelyto signals from the child, thus forming the basis for stable emotional and cognitivefunctioning. If caretakers are not able to sufficiently contain the emotional experiencesof the child, it will develop insecure attachment.

Ainsworth (compare Ainsworth, Blehar, Waters, & Wall, 1978) developed methods tosystematically assess attachment quality by observing toddlers during short separationsfrom their mother. The focus was on registering behavior for fear regulation. The momentof reunification with the mother is crucial. Apart from secure attachment, they distinguishtwo insecure attachment patterns, to wit: anxious-avoidant and anxious-ambivalent.Children with a secure attachment style first ask for comfort and support from theirmother, and then continue to explore the environment independently. Children with ananxious-avoidant attachment style do not ask for comfort from the mother, but stayfocused on their surroundings. These children behave as if the separation does not hurtthem. They do not exhibit a stress response to the outside world. However, when it comesto physiological indications of stress, such as an accelerated heart beat or a high cortisollevel, their scores are the same as those of toddlers who are visibly disturbed. Childrenwith an anxious-ambivalent attachment style display much distress. After they have been

Table 1. Attachment style, markers, and emotion-focused therapy.

ChildrenAdult: Stateof mind Narrative Vocal style Interventions

Secure Autonomous Lived experience Focused: slow,hesitant,pondering

Empathy: follow theprocess

Insecure-avoidant

Dismissing Empty stories Externalizing:rehearsed rhythm

Empathy: Exact,carefulPsychoeducationEvocative reflection

Insecure-resistant

Preoccupied Same old stories Limited: thin, reedy Structure the story Geta specific exampleValidate experience

Insecure-disorganized/fearful

Unresolved IncoherentUnstoriedemotions Brokenstories

Emotional:distorted ordisrupted by theexpression ofemotion

Be predictablePromote autonomyExplain andstructure Articulateemotions andintentions

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reunited with their mother, they continue to pull her close, but they are angry and will notbe comforted easily.

Later, Main and Salomon (1990) described the pattern of a small remaining group whichthey dubbed disorganized attachment. The strategies for coping with stress seem to collapsewith these children. When they are in stress, their behavior becomes chaotic. More recentattachment theory calls this fearful attachment (Bartholomew & Horowitz 1991).

Bowlby (1973) introduced the term “internal working models,” models everybodydevelops on the basis of their attachment experiences. The structure of these modelsdepends on the extent to which one feels that his or her attachment figures are in generalreadily available. Emotional states are frightening when there is no inner working modelof a containing, comforting other.

Adult attachment styles

The adult attachment style can be studied with the Adult Attachment Interview, whichassesses somebody’s state of mind with respect to attachment (Hesse, 1999). An auton-omous state of mind is characterized by a coherent, well balanced and credible discourseregarding one’s relationship with parents along with valuing attachment. A dismissingstate of mind is characterized by minimizing the importance of attachment relationshipsand insistence on personal strength, often accompanied by idealization of the relationshipwith the parents and a striking lack of recall for attachment experiences. A preoccupiedstate of mind is indicated by current enmeshment in the relationship with the parents, asevidenced by the expression of current anger toward the parents or by a passive andconfusing style of discourse. An unresolved state of mind is characterized by lapses inreasoning or discourse when recounting a loss or a trauma. Bifulco et al. (2002) developedthe Attachment Style Interview, a well-validated semi-structured, investigator-basedinterview based on the ability to make and maintain supportive relationships, togetherwith attitudes on several areas: Mistrust, Constraint on closeness, Fear of rejection,Self-reliance, Desire for company, Fear of separation and Anger.

Fonagy (2001) qualifies the classification of attachment styles by speaking in terms ofdimensions. These are derived from the way a number of self-report measures of adultattachment are structured. The structure was found to be determined by two factors: asecure-fearful axis and a dismissive-preoccupied axis. A way of interpreting these data isto assume that secure attachment represents an experience of safety in intimacy, whilefearfulness relates to the disorganization of attachment. The dismissive attachment styleappears to offer protection to the self by isolation, whereas in enmeshed preoccupation,self-protection is perhaps afforded by enlarging the other while denying or subjugating theself. When anxiety increases, the attachment behavior can further disintegrate. Secureattachment can become insecure, reserved behavior can turn into the type of behavior thatcorresponds to preoccupied attachment, and this last type of behavior can degenerate intodisorganized behavior.

People with an insecure attachment style ‘solve’ contradictions in their innerworking models with regard to relations with relevant others by dissociations in theirexperience of the self. According to mentalization theory, people represent experiencesof the self that are irreconcilable with their original personal experience in an alien self(Fonagy et al., 2002). These could be considered as extreme forms of incongruence.People with a disorganized attachment style derive their inner working models frommemories that are dominated by the changing state of the other. Adults who have learntas a child that the state of the parent or guardian is unpredictable remain very alert to

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the state of others, while paying little attention to their own inner experience. Theyfind it difficult to focus on their own feelings, thoughts and sensations, let alone toretain this focus for some time. Self-awareness as such seems to evoke fear and istherefore avoided. Moreover, they do not experience themselves as an integrated andclearly demarcated physical unity. They lack a sense of continuity, which might serveas a starting point for integrated action. Obviously, these dynamics are a severeobstacle to entering into personal relationships, or into a therapeutic relationship forthat matter.

Attachment styles and psychotherapy

Intriguingly enough, Bowlby developed his attachment theory at roughly the same time asRogers (1957) formulated his thoughts about the necessary and sufficient conditions oftherapeutic personality change. The attitude of parents of securely attached children ismoreover characterized by the basic conditions of empathy, respect, and authenticity.According to Rogers (1959), incongruence develops when parents are insufficientlyresponsive to their children or misinterpret their children’s inner feelings. The necessaryand sufficient conditions offer a rectifying experience, helping the client to turn insecureattachment into secure attachment. By viewing attachment styles as coping strategies forprotecting the self, therapists can become more sensitive to clients’ moment-by-momentcognitive-affective processing in therapy.

In the literature on psychotherapy, most attention goes to disorganized/fearful attach-ment, because it seems to predispose people to develop a borderline personality (Fonagyet al., 1995). It is worthwhile, however, to explore the influence of the other insecureattachment patterns, which occur more frequently. When clients respond negatively toempathy, this might indicate an insecure attachment style. This resonates with Warner’s(2000) description of the fragile process: “Clients who have a fragile style of processingtend to experience core issues at very low or very high levels of intensity. They tend tohave difficulty taking in the point of view of another person while remaining in contactwith such experience” (p. 150).

Trijsburg (2007) describes research into the consequences of someone’s attachmentstyle for psychotherapeutic treatment. With respect to clients with a preoccupied attach-ment style, it turns out that there are often no therapy targets formulated. And if they areformulated, they are generally rather vaguely. With respect to clients with an avoidantattachment style, most therapy targets are practical and orientated on a specific complaint.With respect to clients with a secure attachment style, therapy targets often focus oninsight. The attachment style of the client clearly influences the way therapy develops.These research results suggest that clients with an insecure attachment style often do notreceive treatment that addresses the core of their problems. Thus, the neglect of the past isreiterated by their therapist.

Researching the relationship between attachment styles of clients and therapists,Dozier and Bates (2004) conclude that a secure attachment style on the part of thetherapists predisposes them to adequate interventions in relation to the attachment styleof the client. Securely attached therapists tend to challenge clients with a reservedattachment style, while they tend to focus on offering structure with clients who have apreoccupied attachment style.

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Markers for distinguishing between attachment styles

In the literature on emotion-focused therapy (EFT), two sets of markers can be found thatare relevant for the attachment styles mentioned above. Angus and Greenberg (2011)describe differences in the structure of stories. Watson and Greenberg (2000) describedifferences in vocal quality, based on research by Rice and Kerr (1986).

Secure attachment is characterized by a personal narrative, representing lived experi-ence as told stories that unfold along a linear timeline with a beginning, middle, and end.The voice is used in a focused manner. It has a slow, hesitant, pondering quality, as if theclients are trying to find their way in unfamiliar territory, generating new facts ofexperience.

A dismissing state of mind (avoidant attachment) corresponds with a limited vocalstyle. This pattern is characterized by a thin, reedy quality of the voice, as if the clients aretrying to distance themselves from what they are saying. They often tell “empty stories,”stories that are stripped of expected emotional content. Client markers are: focus onexternal details, minimal experiential engagement with the event, stories that arerecounted as if by a disengaged bystander.

Preoccupied clients tend to tell “the same old stories,” stories that are characterized byan overall general description, summarizing a repetitive, maladaptive theme. Clientmarkers include: a pronounced sense of stuckness and helplessness from repetitiveengagement in unrewarding interaction despite negative consequences. Problematic pat-terns are viewed as being maintained by forces outside of the self. The vocal quality isexternalizing. It has a rehearsed rhythmic quality that suggests the client is recapitulatingexperience that has grown familiar and almost stale.

The stories of people with an unresolved state of mind (disorganized/fearful attach-ment) are often incoherent: unstoried emotions and/or broken stories. Unstoried emotionsare an expression of a maladaptive emotional state, devoid of narrative context andunconnected to a trigger. The following client markers can be identified: deregulation ofemotion, absence of discernible causes, lack of understanding for emotions, the feelingthat the client is the helpless victim of a symptom. The vocal style is emotional. It isdistorted or disrupted by the expression of emotion, as when someone attempts to talkwhile sobbing or while laughing heartily.

Emotion-focused therapy, adjusted to insecure attachment styles

Insecure avoidant attachment

Clients with an avoidant attachment style can bear emotions only for a short time. Insteadthey often experience a vague sense of unease and dejectedness. Warner (2000, pp.152–153) describes their experience as follows:

Clients with low-intensity fragile process are likely to have difficulty becoming aware of ortaking their personal reactions seriously. When they do express reactions they often do so insubtle and indirect ways. They are likely to feel rebuffed and withdraw personal connectionbefore others are aware that a serious issue was involved. […] Effective therapy with fragileprocess requires high quality listening skills. Clients typically need more than an acceptingpresence. They need to know that their experience has been understood with exactness andsensitivity as to its emotional vulnerability.

We show in two examples how a careful active approach can help this kind of client todevelop more congruence.

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Client 1

Mister Jansen’s central complaint is that he tends to become emotional without apparentreason these days. He gives the impression of being anxious and inhibited. He finds itdifficult to talk about himself. He sits completely upright, pressing his back into the backof the chair, and the properness of his conduct is almost extreme. When the therapistadopts the client’s posture during supervision, she notices how tense that feels. The thirdsession begins as follows:

T1: Is there something you would like to discuss?C1: Well, I’ve grown tired, more tired.T2: Have you?C2: I don’t know whether it has anything to do with it, but I do notice it.T3: Do you have any idea what might be behind it?C3: Just tired, in its totality.T4: You can really feel it, this tiredness?C4: Yes.T5: So what could be the cause? Could it have something to do with the sessions?C5: Well, I don’t know. But if you say what has changed over the last few weeks, it’s

that. I’ve really grown more tired.

In his fragment Mr Jansen seems very low on the experiencing scale (level 2 according toKlein et al., 1983). By empathic listening his therapist gets an impression of a pervasivesense of impotence. She tries to get in contact by mirroring his experience (T2, 4) andinquiring about his own ideas on the tiredness (T3,5) Both these types of intervention failto improve the level of contact. Mr Jansen is very tense. Through his suffering, he seemsmotivated for therapy. The therapist feels distance in the relation and doesn’t know how tohelp him. Mister Jansen seeks help for his feelings. It worries him that he becomesemotional, while the therapist thinks he suppresses his feelings too much. Her supervisortells her about the fragile process. This helps the therapists to feel empathy for his fear ofemotions. Next the supervision centers on ways to enable Mr Jansen to develop morecongruence in small steps. Psychoeducation about the function of feelings can help tofacilitate this. At first the therapist talks about stress rather than fear, because stress is aless threatening term to the client. She teaches him to become aware of his own stress, bypaying attention to body signals. Then she introduces simple relaxation techniques thatcan help to mitigate stress. After a few months, Mr Jansen and his therapist start tosucceed in finding words for how he feels that are somewhat more specific than “emo-tional” or “tired.” In this case, a supportive approach implies that the therapist refrainsfrom reflecting too much on feelings and instead adopts the rational approach of the client.Only when anxiety has been diminished and Mr Jansen feels free to relax in his chair, thetherapist can start to formulate what feelings she thinks she observes in him. Carefully shecan start to challenge him.

Client 2

Amy has little to say too. In the next excerpt we discuss how she said goodbye to aninternship:

T1: So how was it to say goodbye?

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C1: Well, two days before I had an evaluation with my coach and that went quitestrange.

T2: Strange? In what way?C2: She asked what I’d learnt. I said I’d dared to talk with clients and that that had

gone quite well. Then she started to say that she thought that I wasn’t good at thatat all, and that I still had a lot to learn.

T3: Had that been a point of discussion before?C3: No.T4: [baffled] You mean to tell me she introduced a completely new point of criticism

in your final evaluation?C4: Yes, she never discussed that with me before.T5: How do you feel when you look back on that?C5: Small…T6: Anything else?C6: Agitated… Also a bit angry…T7: Do you feel that somewhere in your body?C7: [thinks for a bit] I guess I feel like pushing away…T8: [gestures pushing something away] Like this?C8: Yes.T9: What would you like to say while doing that?C9: Something like: go away…

After 9 months of client-centered psychotherapy, Amy is capable of experiencing andformulating feelings, but only fleetingly. Her therapist has to keep on asking questions onthe subject and evoke the emotional experience by clearly expressing her own feelings inT4. In T8, she even makes the movement that she suspects Amy has in mind. This seemsto work as an expression of empathy. The conversation does not yet flow from itself; Thetherapist has to keep it going. Every now and then, she leaves the initiative with Amy, butthat results in an unproductive silence most of the time.

Insecure preoccupied attachment

As described above clients with a preoccupied attachment style display a lot of emotion.To make a connection, the therapist needs to validate them emphatically. These clientsoften introduce a tangle of problems. Regular summarization is then an important inter-vention in order to structure their story. These summaries need to fit in with the emotionalexperience of the clients. These clients also tend to localize the source of their problemsoutside of themselves. It can be quite difficult to keep their focus on their own function-ing. This can be illustrated with some exchanges from the first session with a youngwoman:

C1: It’s not going well at all… and well, the most important thing is that… ahm… thatat the moment it’s not going well with my mother at all and that I’m very angryactually that nobody’s coming to help her… ahm… she’s so down and… and I’mafraid she’ll do away with herself and it completely drives me nuts like this…

T1: What I hear is especially your helplessness: what could I possibly do in a situationI can’t handle?

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C2: Yes, you know, this has been going on for ages, it really goes back to when I wasa little kid, she’s just not doing well and she has a lot of dejected periods and… Ijust can’t help her!

T2: There are a lot of problems, it’s really troubling you, I can see how distraught youare. It runs like a red thread through your whole life. And it’s about your motherand you…

C3: Yes, that is the most important thing I guess, yes, I have my own problems too,but…

T3: You mean: what can I do about mother? That’s almost like… how am I doing?…which stays on the background…

C4: Yes… well… she has nobody… nobody but me really… I’ve always tried to helpher and well… it’s just not working anymore…

T4: Not working anymore… Do you mean: I’m failing? I can’t get my mother’ssituation on track?

C5: Well, I’m just scared that… that she… well… that she really does away withherself… in the past… she has…

T5: Wait a minute… You let that drop in passing, but is that what’s making you soupset right now?... Is she going to do away with herself?

C6: Yes, I’m afraid so… when she really does it… then I just don’t want to go onanymore…

T6: Have you ever taken time to let that sink in? What will become of me, if motherdoes herself in?

C7: Well, then I really feel guilty.T7: It’s been a problem all your life, I understand. Keeping mother alive. Keeping

mother as happy as possible.C8: At times it drives me crazy to have such a mother. She can be so mean!T8: Mean?C9: Well… that she never… I’ve never been able to lead my own life, to…T9: If I get it right, then there are two things intermingled right now. There’s your

mother who’s even more suicidal than normal, which makes the danger comereally close. And there’s the feeling you also might have at times, like: what hasbecome of me? Where should I go from here?

In this example we hear a same old story about mother. The therapist uses the facilitatinginterventions of showing empathy, acceptance, involvement and warmth. By summariz-ing, she adds structure to the story. From T2 onwards, she encourages the client to payattention to her own situation and needs. She combines this with validating interventionswith regard to the client’s care for her mother. If she had not done that, she wouldprobably have lost contact with the client. So in this case empathy focuses in particular onthe client’s own needs in combination with her attachment to her mother.

At the end of this first session, the therapist asks the client what she thinks of thesession.

C10: Well, yes, I liked it… My thoughts are so glued together, you know… For me,it’s just a big problem. I do understand now that there are… more sides to it orsomething… I kind of like that…

T10: Do you also like it when I say… you started to laugh then too… that I reallythink this is serious? That this is a turning point in your life…?

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C11: Yes, I think it’s kind of strange to hear that, you know… I have the feeling Ialways have to struggle. People tell me, like: let it go, your mother is yourmother and you are you, live your own life… But I’m always trying to point outto them that it’s not that simple, I’m her daughter and that connection’s justthere, you know… And when I… I’m just not used to it, that somebody says,like: this is just a difficult situation!

Emotional moments are often an indication that something important is being touched.That is why the therapist specifically asks in T 10 about a moment when the client beganto laugh nervously. The client’s answer shows that this form of interaction helps her toclarify her problems and that she feels she is being taken seriously. Thus, the basis for atherapeutic relation has been created.

Insecure disorganized/fearful attachment

For clients with a fearful/disorganized attachment style empathy needs to be fine-tunedvery precisely (Warner, 2000). When the self-regulation of the client is insufficient, thetherapist adopts the attitude of a parent, concentrating on support and clarification. Thisapproach (and its difficulties) can be illustrated with the following case study from a daytreatment program of 3 days a week offering gender specific care for women with earlychildhood traumatization.

Magda has often been abandoned in life, and has been abused by her stepfather as achild. She spent her puberty in three different children’s homes, of which she has onlyfragmentary memories. The course of her day treatment is quite stormy, but after everycrisis we succeed in getting back in touch, so that treatment can be continued.

On Tuesday her group has psychomotor therapy. Psychomotor therapy concentrates onbodily experience. It combines activities from sports and physical education with insightsfrom psychotherapeutic approaches as developed by Pesso (Pesso & Crandell, 1991) andOgden (Ogden, Minton, Pain, & Siegel 2006).

In the break between the warming-up and an activity around the theme “me and mybody,” Magda asks the therapists to explain why they have chosen to focus on a certaintopic during psychomotor therapy. The therapists feel unduly criticized because of thetone with which she raises the subject. One of them asks: “What do you mean?” At thisshe breaks out crying. Now the therapists are totally at a loss as to what might be thematter. They ask Magda more questions, which only increases her confusion. She flees tothe dressing room. One of the psychomotor therapists tells me afterwards that she couldalmost physically feel Magda’s inner confusion in her own body. Later that day wediscuss within the team how we can come to terms with this. Our hypothesis is that thetheme “me and my body” makes her extremely anxious. In her desperation, Magdachooses the attack by criticizing the therapists about the topic she is supposed to workon. A mirroring intervention of the therapists might have been: “I see that you have losttrack of where the treatment is going and that you’re wondering what you can start towork on next. Let’s see if together we can think of something that could help you now.”

On Wednesday, there is no therapy. On Thursday morning, Magda is again veryagitated during group therapy and does not get anything done. When the therapist triesto involve her during the social skills training, she says she wants to leave. The othergroup members respond with irritation: “She’s giving up again.” I (first author) am herpsychotherapist and have time for a short individual consultation. It turns out Magda feelsrejected, because people do not respond when she indicates she needs something. Thus,

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she indicated during psychomotor therapy that she wanted to work on something indivi-dually. And at other therapies, a new group member had taken the place she considered tobe hers. She reiterates a few times: “What’s the point? I just want to go home.” I give backto her that she has apparently arrived at a difficult point in her treatment, where she canchoose between further personal growth through asking attention for her vulnerabilities, orgiving in to fear and losing hope. I propose to her that she go out for a walk for half anhour; when she’s back she can then decide whether she still wants to go home or whethershe wants to stay for lunch and for the final session. Magda agrees and promises to returnin an hour. At one o’clock, before the start of the final session, she will let me know whatshe intends to do. During lunch break, I speak with the psychomotor therapist, who saysshe had not noticed that Magda was asking for attention for something she wanted towork on. We develop the hypothesis that Magda is experimenting with new behavior byactually expressing her needs, but that she does this so bashfully that she is not beingheard; afterwards, she then grows afraid because she has made herself vulnerable andexpects to be abused, just like when she was small.

Magda is neatly on time and says that during lunch she has tried to feel whether shewants to stay in the group or not. She cannot make up her mind. I suggest the abovehypothesis. She immediately recognises it. Nevertheless she sticks to the decision to gohome. I ask her how she wants me to tell the group that she will not attend the finalsession:

Magda thinks for a bit, and then says: “I guess it would be better if I did that myself.”“That would be my preference of course,” I say. “What do you want to tell them?”“That the problem is in me, not in the group member who sat down on my place. And

that it’s too much for me at the moment and that I want to take the weekend to calmlythink through whether I can continue with the group.”

This case study shows how we try to offer Magda a relation of relational depth(Mearns & Thorne, 2000), that is in essence non-directive. Initially Magda’s narrativeseems incoherent and full of unstoried emotions. It is difficult to communicate empathy,because we have to guess what is going on in her. We offer her our hypotheses as neutralsuggestions, so she can test whether they correspond with her inner experience. When sherecognizes what we give her, this clarifies and strengthens her experience. By repeatingthis mechanism time and again, her self-awareness gradually gains in coherence. Thus, wesee she is able to think through her own needs during a break and that she is able to bearher inability to make up her mind. Moreover, she proves to feel enough continuity overtime to postpone the decision until after the weekend. This approach requires thetherapists to refrain from directive interventions. They need to be available for consulta-tion and they need to have faith that the client will be able to make up her own mind.

Conclusion

In this paper we have tried to incorporate attachment in client-centered and emotion-focused therapy. Our first statement is that there is a lot of incongruence and fragileprocess in clients with an insecure attachment. Second we link markers of client narrativesand vocal quality to attachment styles. Of course these associations are tentative. Researchshould show whether there are indeed correlations between attachment styles and thesemarkers. Third we discuss consequences for psychotherapy, illustrated by clinical cases.Avoidant clients are helped best when the therapist soberly responds to what the client istelling them. It can also be productive to normalize their experiences and to diminish theirfears for their own emotions through psychoeducation. With preoccupied clients, it is best

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to add structure by giving short summaries. Their anxiety can be alleviated by explicitlyvalidating what it means for them to live through whatever they are experiencing.Disorganized clients benefit especially when the therapist gives back in no uncertainterms what is happening in the here and now. With all these clients, a cautious andsometimes rather rational approach helps them to gradually discover that it is safe toexperience and share vulnerability. In the clinical cases we show that there is a lot ofthinking required by the therapist to find a way to relate empathically to these clients. Asthe approach is developed in clinical practice it will also provide a challenge for research.

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