Attachment in Psychotherapy (Book Review)

Author:  Wallin, David
Publisher:  Guilford Press
Reviewed By:  Linda Guerra, Spring 2008 (Vol. XXVIII, No. 2), pp. 35-36

Attachment in Psychotherapy, by David J. Wallin. New York: Guilford Press, 2007; 366 PP., $38.00.
Linda Guerra, PhD

In his new book, Attachment in Psychotherapy, David Wallin provides a clear and comprehensive review of the body of attachment theory and research including the work of John Bowlby, Mary Ainsworth, Mary Main, and Peter Fonagy. With this as a foundation, he helps us to see how ideas from attachment theory, intersubjectivity theory and the psychology of mindfulness, can be combined to provide a strong theoretical framework for our clinical endeavors with our patients. In the preface of the book, Wallin states,

I aim to convey how therapists can make practical use of three key findings of attachment research. Accordingly, I focus on the therapeutic relationship as a developmental crucible, the centrality of the nonverbal dimension, and the transformative influence of reflection and mindfulness. (p. xii italics added)

What I love about this book is how Wallin clearly explains and integrates complex theoretical ideas that are currently very popular, ties them to clinical interventions, and offers specific examples from his own psychotherapy practice. He shows us how intersubjectivity theory and the relational perspective have evolved from, and are consistent with, attachment research findings, and indicates how clinicians can productively interact with their patients, depending on the patient’s pattern and predominant style of attachment. Using Mary Main’s Adult Attachment Interview research (p. 207), he tells us what to look for in order to determine if our patient’s attachment style is secure, dismissing, preoccupied or unresolved. Once we have identified the patient’s prevailing attachment style, we can then begin to relate to the patient in ways that provide “an attachment relationship that is friendlier to the patient’s psychological development” than his original attachment relationships (p. 194).

Wallin is careful to point out however, that attachment is complicated, and that people are too complex to simply place in a single category. In addition, he explores the interplay of the therapist’s attachment style with the patient’s, and how this can at times be helpful to the patient, or can result in enactments in which patient and therapist collude to serve the self-protective needs of both. For example,

…a therapist and patient whose predominantly dismissing styles mirror each other, may collude to steer clear of strong feelings. In so doing, they may enact an emotionally distant relationship that is familiar to both. In such a relationship…vital, but anxiety-provoking issues will continue to be avoided. (p. 274)

Wallin finds it useful to think in terms of three stances toward experience: embeddedness, mentalizing, and mindfulness. In describing what he means by embeddedness, he draws on Fonagy’s concept of psychic equivalence (Fonagy et al., 2002) and Melanie Klein’s paranoid-schizoid position. When we are embedded in our experience, “it’s as if we are the experience. . . whatever we sense, feel, and believe at any given moment, we simply take at face value.” In this mode, we are unable to consider alternative views of our experience. To be embedded is to be stuck in our experience and at its mercy. Wallin shows how we can liberate ourselves from the trap of embeddedness, through either the use of mindfulness or the use of mentalization (self-reflection). Both processes foster better emotional regulation, a stronger sense of internal security, and the enhanced “capacities to freely feel, reflect and love.” (p. 166) Thus through the therapeutic relationship, the therapist fosters the patient’s capacities to be reflective and mindful, and gradually the inner void that many of our patients experience, begins to be filled. Wallin believes that sometimes the therapist’s thoughtful self-disclosure is important in facilitating the therapeutic work, although he cautions that it is not appropriate for every therapist with every patient. Utilizing the relational, intersubjective prospective, he stresses that what occurs in a therapy session, is no less a creation of the therapist, than it is of the patient.

Consistent with using attachment theory as a framework, Wallin gives special emphasis to attending to the patient’s nonverbal communication, and believes that it makes sense for the psychotherapist to pay attention to as much of the patient’s experience as possible. He reminds us that Bowlby (1988) theorized that the child excludes from conscious awareness, any thoughts, feelings and behaviors that threaten his attachment relationships. He agrees with many current psychoanalytic thinkers that the patient expresses what he cannot verbalize either through enacting it with others, evoking it in others or embodying it. Therefore the therapist has to attend to what she is thinking, feeling, and/or doing while the session goes on, in order to pick up what the patient is transmitting nonverbally as well as verbally. He also emphasizes the importance of the therapist’s being aware of what is going on in the body, both the patient’s and ours. To help therapists increase their self-awareness, he suggests that we adopt a stance of mindfulness, i.e., an awareness of the present moment with acceptance. Both the therapist’s mindfulness and her teaching her patient to be mindful, assist in increasing awareness of bodily sensations and postures, which in turn can provide access to dissociated feelings and defenses against feelings. Wallin feels that focusing on bodily experience is important for many patients, and essential for patients with unresolved trauma.

In sum, Attachment in Psychotherapy, not only offers instruction in how to make practical use of attachment theory, but espouses an egalitarian approach to psychotherapy, in which the therapist and patient are viewed as flawed human beings who are continuously engaged in trying to create or reenact certain types of relationships with each other. Wallin emphasizes the bidirectional nature of projective identification, and cautions therapists that they must be careful about too readily assuming that what they feel the patient has evoked in them belongs to the patient alone. By addressing both the verbal and the nonverbal realms, and rooting his therapeutic interventions in attachment theory, he provides us with a vision of how to conduct a psychotherapy that is comprehensive, liberating and humane. Reading this book can be a therapeutic experience for therapists and a boon to their clinical practices.

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