Knowing the Self

Attachment and Therapeutic Alliance for Mental Health Professionals

Yusmarhaini Yusof

• Publisher: Bloomsbury Academic
• Year: 2019
• Print ISBN:
  9781352007329
• Edition: 1
• eBook ISBN:
  9781350305779
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

This exciting new book explores attachment, alliance and therapeutic practice. Grounded in theory and built on new research findings based on adult attachment styles, it brings together ideas on attachment and the connections that counsellors and therapists make with the people who seek their help.

1

Introduction

Whether you are a student, a beginning practitioner or an experienced therapist or counsellor, you have probably come across individuals, couples, or families with whom you find it challenging to develop an effective working relationship or ‘therapeutic alliance’. If so, this book is for you.

This book examines the concept of therapeutic alliance and how it is understood in individual and couple or family therapy. I go on to consider the evidence from the perspective of clients, as well as from the perspective of therapists and counsellors, to support the proposition that the alliance is the key to good outcomes. This brings the person of the therapist or counsellor into play – it is my contention that in ‘knowing myself’, I can become a more effective practitioner.

The crucial link I am making in this book is between the therapeutic alliance and the concept of adult attachment. Attachment postulates that we bring with us our learned experiences in forming relationships and that therapists and therapy can be the ‘safe haven’ for clients to explore or repair problematic or ruptured relationships. To become an effective practitioner, you need to consider your contribution that may lead to a successful or failed relationship.

Through understanding our experiences in our family of origin, and, in particular, our ‘attachment style’ as an adult, we can learn to recognise when our own issues intrude in the therapeutic relationship. And, it is this self-awareness that is one of the key ingredients in building good rapport with clients from diverse backgrounds and concerning various issues.

Regardless of your years in practice, or if you are a beginning therapist or someone who would like to learn about attachment and the family of origin issues, this book is suitable for lay persons, educators, practitioners to supervisors, and those involved in an array of health and social care practices from various therapeutic orientations. It can be useful to a novice or an experienced practitioner in reflecting on your own practice in learning about the self or on becoming a therapist. In cases when therapists are ‘stuck’, attachment issues might shed light and provide a new lens to ‘being stuck,’ which may reflect the association between feeling or being stuck with the attachment theory. Our attachment ‘insecurities’ are easily activated or heightened in the event of actual or perceived threat. Therefore, knowing and learning about the self are important ingredients that benefit anyone, especially those in the helping professions.

As you read through the chapters, you will find that this book is suitable for individual or group learning. For instance, it can be used in group teaching sessions or in supervision because it covers issues concerning therapeutic development and therapists’ self-development. It combines the theoretical and research literature on adult attachment and the therapeutic alliance with therapists’ own voices. Throughout the book, I use the term ‘therapist’ to illustrate the therapists’ narratives. Although the book is based on research conducted with family therapists, the experiences described are not confined to family therapists alone and apply just as much to other helping professionals working with individuals, couples, and families, such as social workers, counsellors, psychologists, or mental health professionals.

Thus, this book is written for all helping professionals, particularly therapists and counsellors, to explore the concept of attachment in building relationships with their clients. It draws on a documented journey of 13 therapists who told their stories about how they built their relationships with clients drawing from cases that they brought into a research study. Their voices illustrate how their personal and professional experiences intertwined in their development as therapists. Through the therapists’ accounts, I aim to provide you with an understanding of how the self of the therapist, particularly the adult attachment style and family of origin experiences, has an impact on the relationship the therapist builds with clients. You will have the opportunity to learn from therapists with different attachment styles about their experiences of alliance building.

This book will be useful for you if you work as a therapist, social worker, counsellor, psychologist, or other member of the helping professions who offers interpersonal or therapeutic work to individuals, couples, or families. I hope that this book will appeal to helping professionals across the spectrum and that the experiences of the therapists illustrated in this book resonate with you. I hope that it will enable you to reflect on your practice and learn from it, regardless of whether you are a novice or an experienced practitioner, and whether you are still in training or aspire to become a practitioner.

While previous books have looked at either the attachment theory or the therapeutic alliance, this book offers a different perspective in that it combines the literature of both with a presentation and analysis of therapists’ narratives, to provide insightful knowledge concerning the interplays of these theories. My intention in writing this book is to delve into the heart of building and sustaining therapeutic relationships through an understanding of how the self of the practitioner matters in creating change. I hope that you will enjoy the book as much as I enjoyed researching this topic.

This book starts with a chapter on alliance building and therapy. The concept of alliance from the perspective of individual and family therapy and studies related to both is discussed. The alliance in individual therapy is more straightforward than in couple and family therapy as these involve many people. In individual therapy, a therapist usually works one-on-one with the client whereas in family therapy, the whole family is involved. Hence, alliance building in family therapy is quite complex.

Subsequently the book informs the reader as to why therapists need to know about attachment and the self of the therapist. It tries to engage the reader into looking at the findings regarding the factors that are important to becoming a ‘good’ therapist. It elaborates on one of the factors in particular; namely, the therapist’s adult attachment style. Readers are then presented with a review of the literature concerning the attachment theory and its development. The various definitions of attachment styles are provided based on previous studies, and the link between attachment and therapy is explored.

What comes next is the impact of the personal in the professional world. Readers are introduced to findings from research concerning what motivates people to become therapists before readers encounter the role that the family of origin and critical incidents in the family life of therapists have on their therapeutic work. Therapists’ narratives showing the difference in the style of presentations based on their attachment styles and how personal experiences have an impact on their therapeutic work are also presented. In this chapter, the idea that the therapist is able to be an ‘internal observer’ to his or her past challenges is demonstrated through the therapists with illustrations of various attachment styles, which then leads to the importance of understanding the self of the therapists in practice. Therapists with ‘secure’ attachment styles illustrate the ability to put one’s personal experiences into perspective and use them to guide their work.

The book then focuses on three aspects of alliance building in therapy: engagement, emotional connection, and safety within the therapeutic system. Examples of therapists’ voices are used to illuminate the roles that therapists play in building engagement, creating an emotional connection, and providing safety within the therapeutic system. The accounts of therapists illustrate the differences of the bond factor in alliance building whereby secure therapists are able to connect better with their clients.

Finally, the book concludes with a chapter concerning the importance of continuous training and the role of supervision in therapy. The book captures in therapists’ own voices the importance of supervision, showing the parallel of having a good mentor and becoming a good therapist.

The book draws on a wide range of literature from people like John Bowlby, Mary Main, Chris Fraley, Peter Fonagy, John Byng-Hall, Allan Schore, Mario Mikulincer, Phillip Shaver, Arlene Vetere, Rudi Dallos, Val-entin Escudero, Myrna Friedlander, and Laurie Heatherington, as well as contributions from many other researchers in attachment and alliance. It also draws on my own research on family therapist attachment styles and their therapeutic alliances and covers a range of literature from several therapeutic disciplines including social work, counselling, sociology, and psychology. Throughout the chapters, you are invited to complete a series of exercises that can be used individually in supervision and training to reflect and learn. The exercises draw on your insights and require you to reflect on your formative experiences and their role in building relationships. Exercises are based on case studies or personal reflections that aim to promote self-development. Therapists, novice and experienced, may be susceptible to vicarious trauma or compassion fatigue when dealing with clients’ issues that require empathic responses. Thus, you may find that some of the exercises provide tools to help you in your self-care. It is hoped that this will be beneficial for your continuous training as a therapist. Key summaries of important points and chapters are embedded throughout the book.

From practice to research

The participating therapists in this study were therapists identified as registered family therapists. The list of participants was generated from those who were registered through the UK Council for Psychotherapy (UKCP). From the database, invitations to participate in an online survey were issued to therapists with email addresses. Additionally, the invitation was advertised in Context, the magazine for family therapy and systemic practice. From this, 82 individuals responded to the survey. Subsequently, follow-up interviews were conducted with 13 therapists.

I am forever indebted to them as they opened their busy practices to research, especially to a study that delved into the self of the therapists, which I imagine might have been particularly challenging for some. Additionally, answering personal questions relating to their practices might also have presented difficulties for some therapists.

My encounters with the therapists made me aware of the complexity of conducting research that relates closely to one’s sense of identity and professional work. Hence, I tried to put myself in the therapists’ shoes. In doing so, I noticed how uncomfortable personal questions were to some therapists, as the tables were now turned, and, instead of being the interviewer, they themselves were now in the ‘hot seat’. Thus, being flexible and gauging the suitability of when difficult questions should be asked helped to address the procedural and technical challenges.

Among the participants were those who seemed to struggle with questions relating to their personal experience, and thus I allowed the therapists time to answer difficult questions and respected their silence. I also realised that I brought into the field my own background and identity, which differs from the UK mainstream culture. The process of my interviews with the therapists deepens our understanding of how therapists might relate to clients, especially when their ‘insecurity’ is activated, suggesting that attachment styles do play a role in therapeutic alliances.

I travelled to the venue suggested by the therapists to carry out the interviews. Most interviews took place in either the therapists’ homes or other locations, such as a café or a hotel lobby. I used two recording devices to capture the conversations and the interviews usually lasted for about 60–90 minutes. According to Silverman (2010), the interviewer is an active participant. Hence, I was the ‘research instrument’, and, in the interviews, I was very aware of the sensitivity of the subject matter and my own influence in the setting. Because I am not local, I have a different English accent and I wear a hijab, I anticipated that some therapists would be curious about my own background (Yusof, 2012a & 2012b). I was very mindful throughout the process to gauge participants’ readiness before asking questions that might make some participants uncomfortable. Thus, the focus was on building rapport before penetrat-ing deeper into the subject matter. I found this quite helpful in engaging participants and as a way to lessen their anxiety, as well as mine.

During the interviews, I kept a note of the nonverbal cues, such as ‘moments of silence’, ‘facial expression’ and therapists’ willingness to explore the subject matter. Consideration was also given to pauses, non-verbal gestures, and emotional expressions.

Personal reflection

This book draws upon my research on therapist attachment styles and therapeutic alliances in family therapy. I cannot write about the effect of the personal to the professional self without revealing some aspects of my own personal journey. The interest in this area probably started at an early age, when, as a young child, I was the point of reference to both friends and family. This continued into adulthood when I was consulted for advice. The interest continued to grow, which then led me to choose psychology and subsequently social work as a major in college. I must point out that back then in Malaysia, my awareness of therapists and other professionals in the helping professions was mainly from movies, and I had little idea about the prospect of becoming one in my own country. Nevertheless, I was always intrigued by how the professionals whom I watched in movies assisted their clients. An opportunity arose when I received a scholarship to the United States and was given a choice to choose an area of interest, and one of the available choices was psychology. Though many around me at that time rejected the idea because of cultural norms in which people rarely sought a therapist unless medical attention was warranted, and there was a lack of job prospects in this area back home, I decided to accept the offer. I could now say that, at the age of 17, the prospect of studying abroad was far too enticing to dismiss. However, I never once regretted my decision – in choosing to read psychology, and later social work, and in studying abroad.

To fast forward, my work at the Malaysian Women’s Affairs Department broadened my understanding concerning the plight of women and the issues concerning women’s development in my country, and, later, my formal training continued in a child and family therapy centre in Ann Arbor, Michigan, a place where the language and culture is very different to my own. Initially, I thought my previous undergraduate training in the US and my work experience would have been sufficient to prepare me for the new adventure. But, little did I know that the 18 months’ field work in an outpatient child and family mental health centre would challenge every aspect of my personal and professional development. This was the beginning of a journey that further sparked my interest in therapy and therapeutic relationships. As a young intern, I was eager to enter into therapeutic work and provide the best care for the clients who were assigned to me. Enthusiasm soon turned into doubt – doubting my own capability as a beginning therapist because most of the clients I saw started to drop out from their sessions. I started to ask questions, such as, what went wrong? What could I do to keep them engaged in therapy rather than to drop out? It was questions such as these that led me to think of the things that we can or cannot control in therapy and to realise that these include the therapist’s characteristics. For example, a therapist’s characteristics are uncontrollable traits; hence, what could make a difference, when ‘relating’ or ‘engaging’ with clients, that could go beyond one’s external appearance. Think of your own client engagement, and whether it is easier when there is some similarity between you, as the therapist, and the client, such as cultural similarity or having a similar background.

However, there are also variations and differences within the same cultural context, and it would be naive to assume that a therapist and a client who share similarities should be well engaged. The elements of age, social class, and religion, to name a few, are some of the factors that might either unite or separate us from our clients.

Nonetheless, there are characteristics that surpass all these, such as empathy and understanding, that are essential in building relationships. Thus, as humans, we bring with us the experiences, the teaching, and the upbringing that we acquire from an early age, which theorists such as Bowlby and Ainsworth have termed ‘attachment’. Attachment, which is the focus of this book, proposes that we are the product of our interactions and relationships with our parents, and, as adults, we bring with us ways of relating that are imprinted on us and that might either aid or hinder our capacity or ability to build good relationships. Of particular interest here is the therapeutic relationship, better known as the therapeutic alliance. Hence, what makes a therapist? And, what makes a good therapist?

Essentially, my employment at a university as a social work educa-tor has influenced the way I view therapeutic relationships. In teaching the foundation course in social work practice to social work students, I think that relating to clients very much involves knowing the self of the therapists. Some years later, I had the opportunity to study for a PhD in England and to carry out research on therapy. It was in Bristol that I was able to pursue my interest to research in this area. I attended several conferences on attachment and therapy and through various readings and discussions with my supervisor, I was convinced that attachment is important in the therapeutic relationship. This further deepened my interest in the subject matter, and I started to look at how the therapists in my study used their experience – good and bad – in shaping their work. I soon learnt that ‘good’ attachment does not necessarily mean that everything is ‘perfect’ in one’s life but that it is the work involved in the aftermath that defines a person’s security. Attachment can be disrupted in many ways along the continuum of our life – the death of loved ones, divorce, a chronic illness, or loss can all disrupt our attachment styles. For a therapist, the professional support to continue in this demanding and challenging work is equally important and the role provided by a supervisor will provide an understanding of things that we are unaware of or miss due to our own ‘blind spot’ when dealing with clients and our own personal issues that might influence our work.

Hence, the passion to research this issue grew because it lent me an understanding of the things that I have been through and helped to put things into perspective. Losing a spouse through divorce and the idea of an ‘ideal’ family many years ago challenged how I view things, which very much revolves around attachment. In the event of a loss, our attachment insecurity could easily be activated, and, at that point in life, I could easily have lost myself in self-pity, but what kept me moving was the many attachment relationships that I have; with my God, my parents and my siblings, who continue to support me, and my supervisors and friends. Looking back, I must say that having a supportive environment is a protective factor as well as a relief. Of importance is my role as a mother to two young girls, which is a crucial aspect that motivates my interest to understand attachment and relationships. Having grown up with two supportive parents, I felt a sense of remorse at what I have to put my children through. My wish to unders...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Exercises
• List of Figures, Tables and Case Studies
• Acknowledgements
• About the Author
• 1 Introduction
• 2 Alliance Building
• 3 What Therapists and Counsellors Need to Know about Attachment
• 4 The Impact of the Personal on the Professional World
• 5 The Relationship between Attachment Styles and Alliance: Therapists’ Stories
• 6 Continuing Professional Development and the Role of Supervision
• References
• Index