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An Essential Guide for Science-Based Practice
The most exciting breakthroughs of the 21st century will not occur because of technology but because of an expanding concept of what it means to be human.
— John Naisbitt
Proximity to social resources decreases the cost of climbing both the literal and figurative hills we face, because the brain construes social resources as bioenergetic resources, much like oxygen or glucose.
— James A. Coan and David A. Sbarra (2015, p. 87)
There are now over a thousand different names for approaches to psychotherapy and 400 specifically outlined methods of intervention (Garfield, 2006; Corsini & Wedding, 2008). There are also numerous therapy "tribes" each with its own view of reality. Approaches and methods vary widely in the extent of their specification, the depth of theory they are based on, and the level of empirical support they have accrued. In addition, there are literally hundreds of specific in-session interventions for any problem a client can come up with. These interventions are often portrayed as fast cures for complex disorders, the focus being on symptom reduction rather than on considering the person and context in which this symptom arises. Having all these methods and techniques out there, purportedly with at least some level of rigor behind them, strikes me as a perfect recipe for chaos in our field.
FOUR ROUTES OUT OF CHAOS
In the face of escalating numbers of "disorders" (which proliferate with every version of classification systems, such as the DSM), models, and interventions, the need to find clear, general, and parsimonious routes to training and intervention is obvious. Four routes seem to offer promise. The first is the path of dedicated empiricism. Conscientious therapists are exhorted to take the path of science, read all the empirical research, and then choose the best perspective, model, and intervention for each client's presenting problem at a particular time. Even for the most dedicated therapist, this seems like a daunting, if not impossible, task, especially since manualized treatment protocols are becoming more numerous, complex, and arduous to master. Under dedicated empiricism, the practice of therapy becomes one of following a set cognitive outline, and the therapist becomes primarily a technician.
The second path involves focusing on the process of change in therapy. The most concrete attempt at parsimony here seems to be the suggestion that therapists simply focus on common factors in the therapy change process, whatever and whoever they are trying to change. The justification for this orientation is that all treatments in large outcome studies seem to be equally effective, so specific models and interventions are interchangeable. In fact, this generalization is unfounded and is based on placing many different studies of varying quality into a soup called meta-analysis, and coming up with mean results that are often meaningless. In fact the whole idea of interchangeable effects across therapies would seem to be an artifact of evaluation methodology (Budd & Hughes, 2009); different manualized therapies often share a large number of active ingredients. There are also some areas in which specific treatments have been found to be more appropriate and more effective for specific disorders (Chambless & Ollendick, 2001; Johnson & Greenberg, 1985), although it is not clear if such differences are maintained at follow-up (Marcus, O'Connell, Norris, & Sawaqdeh, 2014).
Perhaps the most considered variables in the study of general change factors seem to be the quality of the alliance with the therapist and client engagement in the therapy process. The promise is that, if we get these general factors right, then suddenly the task of therapy — to create change — will become simple and manageable. A positive alliance and attention to the quality of client engagement are probably necessary for any kind of change; they are certainly key variables that potentiate the process of change. But they are hardly the whole story when it comes to intervention. The amount of variance in outcome accounted for by the alliance with the therapist has been calculated at around 10% (Horvath & Symonds, 1991; Horvath & Bedi, 2002). Furthermore, general factors become less general in the therapy room. Is alliance as operationalized by an experiential humanistic therapist the same as that shaped by a cognitive behavioral therapist? The concept of client engagement seems more promising. In the National Institute of Mental Health (NIMH) study of depression, Castonguay and colleagues found that more emotional engagement/experience on the part of clients predicted positive change across therapy models (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996), whereas a focus on distorted thoughts as they link to negative emotions (as exemplified by classic cognitive-behavioral therapy [CBT]) actually predicted more depressive symptoms after therapy. Of course, the level of engagement that is deemed sufficient for change will surely vary depending on the goals of a particular model of therapy.
A third proposed route to achieving clarity and efficiency in our field is to focus on commonalities in the problems clients bring to us. The promise here is that we can integrate areas of intervention focused on the so-called latent structure of, for example, emotional disorders (such as panic disorder, generalized anxiety disorder, and depression), viewing all these problems as a more general negative affect syndrome. Therapists then might work on modifying a small number of empirically outlined key symptoms of such general malaise. Negative affect syndrome, for example, can be defined as an overactive sensitivity to threat, a habitual avoidance of fearful situations, and automatic negative ways of responding or acting when triggered (Barlow, Allen, & Choate, 2004). Change is all about helping clients to reevaluate such threats and reduce catastrophizing, which makes it possible for them to then modify their habitual avoidance of fearful situations (which has prevented new learning and paradoxically maintained their anxiety). It should then be possible to persuade the client to actually respond in a different way when exposed to a negative trigger. Of course, the best ways to "persuade" and "reevaluate" are still unclear.
A fourth route is to focus on underlying processes, not just in the development of a disorder, but in the way people function when thriving and when dysfunctional. This equates to a broad orientation to how human beings continually construct a sense of self, make choices, and engage with others. From this vantage point, we understand why psychotherapy has evolved, not just in terms of following specific evidence-based interventions, grasping general common elements in therapy, and cataloging descriptions of client problems, all of which are useful, but also from general models of human functioning, that is, from attempts to depict and understand just what kind of creature a human being is. Such models offer therapists general definitions of health and positive functioning, and dysfunction and distress that go way beyond the disorders delineated in the formal classification systems (such as the DSM or ICD). The most current and most robust of these models call for therapy to focus on the whole person in his or her life-operating context. They call for the agenda of therapy to broaden in order to embrace growth and the optimal development of the personality, rather than focusing strictly on the relief of one or more specific symptoms. A broad conceptual model allows us to place descriptions of disorders and of core elements of change into an integrated explanatory framework. From this framework, we can assess clients' strengths and weaknesses and decide how best to engage with them. We can also make judgments about what changes really matter and are likely to last. All models of therapy are based on some kind of implicit model of human functioning, but these are often left vague or unexamined. The cognitive behavioral model of couple therapy, for example, is based on a rational economic model of close relationships, wherein skilled negotiation predicts relationship satisfaction. Emotionally focused couple therapy, on the other hand, is based on a model of relationships that prioritizes emotion and bonding processes and views emotional responsiveness as the key ingredient in satisfaction and stability.
No single perspective or model can capture the richness and complexity of a human life; as Einstein said, "Alas, our theory is too poor for experience." However, in order for clinicians to operate in an optimally efficient and effective fashion, we need a cohesive science-based theory of the essentials of human functioning that is capable of addressing emotional, cognitive, behavioral, and interpersonal dysfunction. This theory must apply across the modalities of individual, couple, and family therapies, and it must offer the three basics of any scientific endeavor: Systematic description based on observation and the outlining of patterns; predictions linking one factor to another; and a general explanatory framework, which must be supported by a large corroborating body of research. It must be convincing and falsifiable in its portrayal of optimal functioning and resilience, of the development and growth of a person over time, of dysfunction and how it is perpetuated, and of the necessary and sufficient conditions for meaningful lasting change.
Specifically, psychotherapy needs a theory (or a pathway or map) that guides us to help people to change on the level of core organizing variables, such as how emotion is habitually regulated, how core orienting cognitions about the self and other are structured and processed, and how pivotal behaviors and relationships with others are shaped. This theory has to step beyond the intrapsychic; it has to link self and system, intrapsychic individual realities, and interactional patterns in a parsimonious and systematic way. It has to correspond with the new cutting-edge research on neuroscience and the evidence that we are, more than anything else, social animals fixated on our connection with others.
ATTACHMENT THEORY: WHO WE ARE AND HOW WE LIVE
I submit that there is only one candidate that comes anywhere near fulfilling these criteria, and that is the developmental theory of personality termed attachment theory, as outlined by John Bowlby (1969, 1988). While initially attachment theory was presented in terms of early childhood development, it has been extended, particularly in the last few years, to adults and adult relationships. As Rholes and Simpson point out (2015, p. 1), "Few theories and areas of research have been more prolific during the past decade than the attachment field. ... The ensuing flood of research that now supports the major principles of attachment theory rank among the most important achievements in the psychological sciences today." In addition, attachment science is consonant with current research from the fields of neuroscience, social psychology, health psychology, and clinical psychology, the central message of which is that we are first and foremost a social, relational, and bonding species. Over the lifespan, the need for connection with others shapes our neural architecture, our responses to stress, our everyday emotional lives, and the interpersonal dramas and dilemmas that are at the heart of those lives.
Recently attachment theory has been explicitly proposed by Magnavita and Anchin (2014) as the basis for a unified approach to psychotherapy. These authors suggest that this theory constitutes the long-sought-after "holy grail" that finally allows for a cohesive approach to a wide array of psychological disorders and addresses character change and permanent symptom alleviation. Others have recently suggested that attachment theory offers a substantive basis for intervention in a number of specific modalities, such as individual psychotherapy (Costello, 2013; Fosha, 2000; Wallin, 2007), couple therapy (Johnson & Whiffen, 2003; Johnson, 2002, 2004), and family therapy (Johnson, 2004; Furrow, Palmer, Johnson, Faller, & Palmer-Olson, in press; Hughes, 2007). All these authors stress the essentially integrative nature of attachment science and theory, and that this perspective allows us to move beyond compartmentalization and fragmentation into what E. O. Wilson terms "consilience" (1998). This term arises from the ancient Greek belief that the cosmos is orderly, and that this order can be discovered and systematically laid out in a series of interacting rules and processes. These rules emerge from the convergence of evidence drawn from different sets of phenomena and come together to give us viable blueprints for our world and ourselves.
PRINCIPLES OF ATTACHMENT THEORY
So what are the basic tenets of modern attachment theory that have evolved from the first model so brilliantly outlined by John Bowlby (Bowlby, 1969, 1973, 1980, 1988) and developed further by social psychologists in more recent years (Cassidy & Shaver, 2008; Mikulincer & Shaver, 2016)? I'll set forth 10. But first, note three general facts about this perspective. Attachment is fundamentally an interpersonal theory that places the individual in the context of his or her closest relationships with others; it views mankind as not only essentially social but also as Homo vinculum — the one who bonds. Bonding with others is viewed as the most intrinsic essential survival strategy for human beings. Second, this theory is essentially concerned with emotion and the regulation of emotion, and it particularly privileges the significance of fear. Fear is viewed not only in terms of everyday anxieties, but also on an existential level, as reflecting core issues of helplessness and vulnerability; that is, as reflecting survival concerns regarding death, isolation, loneliness, and loss. A key factor in mental health and well-being is whether these factors can be dealt with in a manner that enhances vitality and resilience. Third, it is a developmental theory; that is, it is concerned with growth and flexible adaptiveness and the factors that block or enhance this adaptiveness. Bonding theory assumes that the close connection with trusted others is the ecological niche in which the human brain, nervous system, and key behavioral patterns evolved and is the context in which we can evolve into our best selves.
In simple terms, the 10 core tenets of attachment theory and science are:
1. From the cradle to the grave, human beings are hardwired to seek not just social contact, but also physical and emotional proximity to special others who are deemed irreplaceable. The longing for a "felt sense" of connection to key others is primary in terms of the hierarchy of human goals and needs. Humans are most acutely aware of this innate need for connection at times of threat, risk, pain, or uncertainty. Threats that trigger the attachment system may be from the outside or the inside, for example, troubling construals of rejection by loved ones, negative images or concrete reminders of one's own mortality (Mikulincer, Birnbaum, Woddis, & Nachmias, 2000; Mikulincer & Florian, 2000). In relationships, shared vulnerability builds bonds, precisely because it brings attachment needs for a felt sense of connection and comfort to the fore and encourages reaching for others.
2. Predictable physical and/or emotional connection with an attachment figure, often a parent, sibling, longtime close friend, mate, or spiritual figure, calms the nervous system and shapes a physical and mental sense of a safe haven where comfort and reassurance can be reliably obtained and emotional balance can be restored or enhanced. The responsiveness of others, especially when we are young, tunes the nervous system to be less sensitive to threat and creates expectations of a relatively safe and manageable world.
3. This emotional balance promotes the development of a grounded, positive, and integrated sense of self and the ability to organize inner experience into a coherent whole. This grounded sense of self also facilitates the congruent expression of needs to attachment figures; such expressions are likely to result in more successful bids for connection, which then continue to build positive models of close others as accessible sources of support.(Continues…)
Excerpted from "Attachment Theory in Practice"
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Table of Contents
Chapter 1 Attachment: An Essential Guide for Science-Based Practice, 1,
Chapter 2 Attachment Theory and Science as a Model for Therapeutic Change, 24,
Chapter 3 Intervention: Working with and Using Emotion to Construct Corrective Experiences and Interactions, 43,
Chapter 4 Emotionally Focused Individual Therapy in the Attachment Frame: Expanding the Sense of Self, 74,
Chapter 5 Emotionally Focused Individual Therapy in Action, 101,
Chapter 6 Getting to Safe and Sound in Emotionally Focused Couple Therapy, 125,
Chapter 7 Emotionally Focused Couple Therapy in Action, 160,
Chapter 8 Restoring Family Bonds in Emotionally Focused Family Therapy, 179,
Chapter 9 Emotionally Focused Family Therapy in Action, 205,
Chapter 10 A Postscript: The Promise of Attachment Science, 222,
Appendix 1 Measuring Attachment, 231,
Appendix 2 General Factors and Principles in Therapy, 237,
Appendix 3 Emotionally Focused Individual Therapy and Other Empirically Tested Models That Include the Attachment Perspective, 243,
Clinical psychologists, couple and family therapists and counselors, social workers, psychiatric nurses, and psychiatrists. Will serve as a supplemental text in graduate-level courses.