Integrative Psychotherapy Articles
Attachment, Relational-Needs, and Psychotherapeutic Presence
Richard G. Erskine, Ph.D.
Keynote address: International Integrative Psychotherapy Association Conference in Vichy, France, April 21, 2011
From birth to death we are motivated by our biological need for attachment - the need to be in relationship. Relationship is a biological imperative that exists throughout our lives.
Who we are and what we achieve occurs in an extensive matrix of relationships. It is through these emotional attachments and because of these relationships that we exist, grow, change, and achieve the things we do in life.
Our matrix of relationships constitutes a life-giving, nurturing and stimulating network of attachments (Trautmann & Erskine, 1999).
"To be human is to be in relationship with others"
(Erskine, Moursund, & Trautmann, 1999, p. 4).
We cannot avoid being connected with others. None of us exists except in relationship; we are born in relationship and need relationships to know who we are in this world. The essence of our humanness is inextricably tied up in our attachments and the ways we relate to others. We are conceived and born within a matrix of relationships and we live all our lives in a world that is inevitably and constantly populated by other humans --- even when we are in a fantasy, we are often in relationship with someone, either approaching someone or distancing from someone.
Developing the many relationships that we have is a fundamental aspect of our growth (Gazzaniga, 2008). We cannot live as humans without relationships, and our environment must provide us opportunities to develop and use them as we move through life. Every person, and especially every child, requires relationships in which the other person is reciprocally involved. We require the contactful presence of another person who is sensitive and attuned to our relational-needs and who can respond to them in such a way that the needs are satisfied (Clark, 1991).
As therapists, we frequently find ourselves working with clients for whom such relationships have not been consistently or dependably available. Such clients experience not only the needs of a here-and-now relationship, but the unmet relational-needs of past insecure attachments as well. Our therapeutic presence, our attunement, and our involvement must extend beyond the needs of the present; we must also be responsive to our client's old unmet needs -- not that we must satisfy those archaic needs. Attempting to satisfy a relational-need of a previous decade is an impossible task. In an in-depth relational psychotherapy we respond to our client's un-met archaic needs through our attunement, acknowledgement, explanation, and validation so that the client can understand and appreciate his or her own experience of being. Often the intensity of old unmet relational-needs overshadows and distorts the relational-needs of the here-and-now therapeutic relationship. A major task of the psychotherapist is to help the client differentiate between current needs and archaic needs.
Relational-needs are present throughout the entire life cycle from early infancy to old age. People do not outgrow their need for relationship. These needs are the basis of our humanness. Even as adults we attach to others because we perceive them as being able to satisfy our variety of needs.
When our relational-needs are met, we have the capacity to be expansive, creative and intimate. When relational-needs are repeatedly not met, we experience a sense of insecurity and emotional disturbance. We adapt to this insecurity by developing attachment styles or patterns that compensate for the disruption in relationship. These insecure attachment styles and patterns are the result of repeated disruptions in significant relationships. Often these insecure attachment styles and patterns become fixated and endure over a long period of time. Another major task of psychotherapy is to help our clients resolve their fixated insecure attachment patterns.
When a child's caretakers are inconsistently responsive in satisfying the child's relational-needs, a pattern of clinging and over-dependency develops -- a pattern wherein the child is nervous, constantly focused on the caretaker, and worried about the loss of nurturance. The phenomenological experience of such relational inconsistency is in a sense of "neediness". The person becomes sensitive to other's misattunements and highly adaptive to others in order to get some semblances of his or her needs satisfied. Later in life they often experience that other people will not take their needs seriously. They have an implicit fear of loss of relationship and will often do anything to cling to a relationship even if it is not good for them.
This history of inconsistency in need satisfaction results in a pattern of attachment that is uniquely different from those who had caretakers who were predictably unresponsive to the child's relational needs. When parents, caretakers, teachers or other significant people are consistently emotionally unavailable and predictably unresponsive to relational-needs, the child's needs for security, validation, or self-definition get ignored. When a child's feelings and needs are consistently ignored eventually the child can predict that "I will not get any emotional sensitivity" or "My needs will not be met". In these situations children often give up trying to be connected to significant others or they may even give up sensing their own needs. A child who lives with significant relationships that are consistently misattuned and emotionally unresponsive may later in life compensate for the lack of need satisfaction by avoiding intimacy and undervaluing the importance of relationship. They may appear to be emotionally detached and even disdainful of their own or other people's needs and emotions because they have an implicit fear of vulnerability.
When significant people in a child's life are predictably punishing, particularly when the child is in the midst of expressing his or her relational-needs, there is a disorganizing traumatic reaction within the child's brain and body. This disorganization is profoundly disturbing internally hence subsequently in relationships. If the very person on whom the child depends for need satisfaction is the same one who is predictably punishing, then the child's experience of body sensations, affects, needs, and relationship will be profoundly confusing. This confusion may endure later in life as a highly disorganized style or pattern of attachment because they have a physically intense implicit fear of violation.
When a child's natural dependency on significant others for their satisfaction of relational-needs is repeatedly met with invasive and controlling caretaking --- an accumulation of rhythmic and affect misattunements --- the child may then develop patterns of relationship and attachment marked by a social façade, psychological withdrawal, and the absence of emotional expression. People with an isolated attachment style or pattern have an implicit fear of invasion that is reflected in the both their diminished affect and withdrawal in interpersonal contact. To be authentic is sensed as dangerous.
I have been describing four styles or patterns of insecure attachment. Each has its antecedents in the quality of relationship that the child has experienced in his or her history of relationships. And each of these four types of attachment is based in a sub-symbolic, implicit fear: fear of the loss of relationship, fear of vulnerability, fear of violation, and/or fear of invasion. These four classifications of attachment are based on the research and clinical writings of a number of authors (Ainsworth et al, 1978; Doctors, 2007; Hesse, 1999; Main, 1995; O'Reilly-Knapp, 2001). However, clinical experience has shown that there are many more insecure attachment styles, patterns and disorders than the four mentioned here. Any of these four may be in combination with the other three. There may also be distinctly unique expressions of attachment that our client's may reveal to us if we are sensitive to the unconscious expression of their relational history and how that attachment history is enacted in the here-and-now. As psychotherapists we must look beyond this limited taxonomy of relationships and discover with the client his or her unique ways of being in connection with others.
In fact, we each may have more than one attachment style or pattern. Children develop in a matrix of relationships wherein each significant other may respond to the child's relational-needs in a different way. Over time children may develop one type of attachment with mother, another with father, and another with an older or younger sibling. Teachers from preschool to university, as well as peers (particularly during adolescence), have a significant impact on a child's various ways of being in relationship. Each of these interpersonal influences forms the person's unique matrix of relationships --- a matrix that may be composed of different styles of attachment, each of which may be used in a different relational situation.
Bowlby described secure attachment as emerging from the mutuality of both the child's and caretakers' reciprocal enjoyment in their physical connection and emotional relationship. Children grow up with a secure attachment when caretakers enjoy satisfying the child's relational-needs -- such as the need for validation, the need for companionship, the need to have some one "stronger and wiser" to lean on (Bowlby, 1988, p.12), or the need to influence what is occurring in the relationship.
I have just mentioned four relational needs. In the qualitative research conducted at the Institute for Integrative Psychotherapy on the needs essential in human development, eight relational needs were identified in our factor analysis (Erskine, 1998). Although there may be a large number of relational-needs, the eight to which I am referring represent those needs that clients most frequently describe as they talk about significant relationships. Relational-needs are the needs unique to interpersonal contact; they are not the basic physiological needs of life, such as food, air or proper temperature. They are the essential psychological elements that enhance the quality of life and the development of a positive sense of self-in-relationship (Erskine & Trautmann, 1996/97).
Relational-needs are the component parts of a universal human desire for intimate relationship and secure attachment. They include 1) the need for security, 2) validation, affirmation, and significance within a relationship, 3) acceptance by a stable, dependable, and protective other person, 4) the confirmation of personal experience, 5) self-definition, 6) having an impact on the other person, 7) having the other initiate, and 8) expressing love (Erskine, Moursund & Trautmann, 1999).
Mary Ainsworth and her research colleagues (1978) found that mothers of secure infants were attuned to the affect and rhythm of their babies, sensitive to misattunements, and quick to correct their errors in attunement. There are five implications in both this research and in Bowlby's writings (1969, 1973, 1980) for the effective practice of psychotherapy. The five essential components are:
1) the necessity for the therapist's on-going attunement to the client's rhythm and affect;
2) the importance of the therapist's sensitivity to his or her therapeutic misattunements;
3) the significance of the therapist taking responsibility for therapeutic errors;
4) the therapist's awareness of and flexibility in responding to the client's changing relational-needs; and
5) the importance of the therapist's vitality and reciprocal enjoyment in the relationship with the client.
The healing of insecure attachments occurs through a contactful therapeutic relationship --- a relationship replete with respectful inquiry, acknowledgement, validation, and the normalization of both relational-needs and the client's style of compensating for unmet needs. If we are to be effective in healing our client's fixated, insecure attachment patterns such inquiry, validation, or normalization must always be based on a foundation of sustained affective attunement.
Attachment Style, Pattern and Disorder
It is time to make a distinction between attachment style, attachment pattern and attachment disorder. I relate these three categories to the extent, pervasiveness, and quality of relational disruptions throughout the client's history. I think of these three categories on a continuum from mild to moderate to severe. We all have a repertoire of attachment styles. We cannot escape the multiple influences of our rich history of relationships. An attachment "style" is not particularly problematic to the person or to others. To know and appreciate our style of attachment is often useful in managing current relationships and in understanding our dynamics with others.
Attachment "pattern" refers to a more problematic level of functioning with other people on a day-by-day basis. Often an individual's repetitive attachment pattern is more uncomfortable to family members and close associates than to the individual. An attachment pattern is more pervasive and problematic than an attachment style.
Attachment "disorder" refers to a person's continual reliance on fixated childhood models of relationship and archaic methods of coping with relational disruptions. An individual's archaic form of coping and attachment is pervasive in nearly every relationship with people and in nearly every aspect of the person's life (Erskine, 2009).
The concept of psychotherapeutic presence is illusive. It is like trying to describe a handful of fog. You can see the fog, feel it on your skin, even taste it, but describing a handful of fog requires the imagination of a poet. In the same way we can feel the presence of someone who is contactful. When someone is fully "with us" and "for us" we can feel the vitality of the communication even when it is non-verbal. But describing presence is illusive because presence is an ever-changing human dynamic. Presence is more than just communication; presence provides a sense of interpersonal communion.
Psychotherapeutic presence begins with the therapist's attitudes about each client. Carl Rogers described his attitude toward his clients as "unconditional positive regard" (Rogers, 1951). Martin Buber chose the term "I-Thou" to illustrate his attitude that the other person was sacred (Buber, 1958). The intersubjective psychoanalysts describe the attitude of "being with" their client in the term "sustained empathy"(Kohut, 1977; Stolorow, Brandschaft & Atwood, 1987). I have described that psychotherapeutic presence occurs when the attitude, behavior and communication of the therapist consistently respects and enhances the client's integrity (Erskine, 1998).
Presence occurs when the therapist de-centers from his or her own needs, feelings, fantasies, or hopes and centers instead on the client's process. It involves being fully mindful of the client: watching every little movement and gesture; listening to every word, sound and even the silence. It includes being fully with them in their silences, embracing the pregnant pauses so the client can discover the full extent of his or her feelings and experiences. Presence also includes the converse of de-centering; that is, the therapist being fully contactful with his or her own internal processes and reactions. The therapist's history, relational-needs, sensitivities, theories, professional experience, own psychotherapy and reading interests all shape unique reactions to the client. Each of these thoughts and feelings within the therapist are an essential part of therapeutic presence. The therapist's repertoire of knowledge and experience is a rich resource for attunement and understanding. Presence involves both bringing the richness of the therapist's experience to the therapeutic relationship and de-centering from the self of the therapist and centering on the client's process.
Presence is provided through the psychotherapist's sustained attuned responses to both the verbal and non-verbal expressions of the client. Presence includes the therapist's receptivity to the client's affect --- to be impacted by their emotions and yet to stay responsive to their emotions; to not become anxious, depressed or angry but to stay calm and patient. Presence is an expression of the psychotherapist's full internal and external contact. Therapeutic presence occurs when full interpersonal contact is combined with therapeutic intent and therapeutic competence (Yontef, 1993). It includes the therapist's ethical commitment to the client's welfare.
Presence involves using all the information gained through inquiry and all the sensitivity of attunement to maintain a genuine, caring and responsible relationship within which the client can find the support he or she needs in order to relinquish old attachment patterns and disorders and find secure attachments in their current lives.
Presence describes the therapist's provision of a safe interpersonal connection. The dependable, attuned presence of the therapist counters the client's insecure attachment and the discounting his or her self-worth. The quality of presence creates a psychotherapy that is unique with each client, attuned to and involved with the client's emerging relational-needs. Through the therapist's full presence, the transformative potential of an integrative, relationship-oriented psychotherapy is possible.
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Humans require the contactful presence of another person who is attuned and responsive to relational-needs. Insecure attachment patterns are the result of repeated disruptions in significant relationships. This article describes eight relational-needs that, when repeatedly unsatisfied, lead to insecure attachment patterns based on the fears of loss of relationship, vulnerability, violation, and invasion. The healing of insecure attachment patterns occurs through a contactful psychotherapeutic presence that occurs when the attitude, behavior and communication of the psychotherapist consistently respects and enhances the client's integrity while responding to relational-needs.
Copyright: Institute for Integrative Psychotherapy and Richard G. Erskine, PhD, 2011