Keywords

Attachment; Adult counseling; Anxiety; Single case study; Culture

Introduction

Attachment theory has significant implications in counseling work with adults. The comprehension of attachment in psychological health setting has certain complexity and ever evolving [1]. Conversely, a firm consideration of a client’s attachment drives counseling process in more dynamic way. A counseling psychologist with expertise over attachment styles would be more equipped with resilience and menaces of that particular attachment style and provide further insight to suitable counseling techniques and perspectives. Current paper will discuss how the principles of attachment theory have implications and prolific association in the case of adult’s anxiety.

John Bowlby adapted and improved Freudian outlook that humans are driven by their impulses with his attachment style theory [2]. Bowlby viewed humans as forced by their relations and by their needs to attach to chief caregiver in infancy. John Bowlby (1940, 1944, 1958, 1980) proposed that children are instinctive for specific attachment dispositions towards their caregivers and learn to form their behaviors and reasoning for the preservation of relationships [3-5]. He further added in caregiver relationship which is fundamental to children’s mental and physiological survival. Furthermore, attachment theory [6] accentuates that children usually brook no caregiver relationship but at substantial controls to their own working which may change in children’s feelings and reasoning patterns that occurs characteristically in reaction to the parents’ ineffectiveness towards meeting children’s needs for wellbeing, security, and emotional reinforcement. Attachment theory focused on an individual’s internalization of the experience of his/her primary caregiver and in view of others in presence will transform to the primary caregiver. Bowlby postulated that attachment theory has association with the children’s understanding but more studies have been emerging that focuses on practicality of attachment theory on adults [7-9]. Current strong empirical evidence for Bowlby’s views showed that initial family experiences related to future personality development and interactions [10]. Furthermore, contemporary theoreticians postulated that adults have similar attachment desires with those of children and that need meet through adult attachment relations with spouse, family members and peers [11].

Current implication of attachment theory of adulthood has reflected that how infant patterns of attachment presented as interpersonal and even sometimes irrational patterns in adulthood [6,9,12]. In childhood as Sable (2000) added, environmental discrepancies like unreliable and/or refusing caregiving, impact adversely on healthy growth and present equivalent distortions and absence of consistency in working models that remained in affecting an individual as in child and adult. Indications of anxiety, depression, or anger, thus, are reactions to interferences of personal bonds. Sable’s account has significance in clinical work as it consents mental health practitioners to re-conceptualize adult symptomatology in attachment patterns. Adult indicators of anxiety may be suggestive of problematical internal working models of them, rather than biological phenomenon as proposed by scientific community. Indicators and symptoms of anxiety and depression could be product of an adult’s less than stimulating interpersonal relationships which transformed into isolation and interpersonal issues rooted in problematic primary care.

Re-conceptualizing process in attachment terms suggested a reconsidering of the objectives of adult counseling. Holmes (2001) proposes that the goal of counseling can be précised in the search for autonomy and intimacy [12]. And that the capability for intimacy comes out of the attunement, whereas a sense of autonomy arises from the effective manifestation of the vigorous dissent where loss is irrevocable, grief-stricken. He believes in counseling as reiterating of early processes in autonomy and intimacy and consequently therapeutic relief of adults’ primary experiences with caregivers. Holmes impression focused with the aims of counseling to provide an atmosphere which stimulates attunement in an individual, secure enough to cope up with pertinent remonstration and therefore ascends innovative implications. Sable (2000) identified the working model of the counseling relationship eventually brandishes supremacy over upsetting experiences and former models of childhood contradicting the client’s image of oneself as unlovable and undeserving of secure affectionate ties [10]. Both Homes and Sable conceptualize counseling in the practice of remedial adults’ distress through attuned, empathized association between client and the counseling psychologist. Both Holmes and Sable also perceive this linking in provision of reparative social experiences for a client, experiences which will ultimately lessen client’s pain. Attachment theory, hence, provides a structure in which to outlook adult counseling in a unique way. A case study and case report could better illustrate the implication of attachment theory to adult counseling process. This case example emphasized on the attachment relationships, the meanings underlying those relationships and how they obstructed the therapeutic process and its objectives.

Maria (hypothetical name) was a 23-years-old college female student, who referred herself for the counseling. She presented to the individual one-to-one counseling because of her concerns about her anxiety. She reported in her presenting complaints that problem with anxiety continued for several years including the symptoms of feeling physical discomfort, dry mouth, panic attack and avoidance of situation. She noted that she has been experiencing symptoms of anxiety since grade six when two schoolboys tried to get physically close to her and barge at her home claiming that she invited them. Of that she told her mother about and her mother talked to the school principle over she felt so embarrassed that everyone knew about. After that incident, her mother changed her school forcibly and she became insecure that she can never trust anyone. When Maria began counseling, she displayed symptoms of anxiety overtly. Her voice and gait was slow taking long pauses between phrases and her slow walking pace was consisted of fidgeting with her bag or dress. Maria was about to be graduated in few months from an undergraduate program from co-education college. She was residing in a city almost 45 minutes away from her undergraduate college and reported that she was lonely most of the time and felt she could be revealing her anxiety to anyone anytime. She had only one friend but she felt that their friendship was more important to her than to her friend.

Client described her relationships with her family as tenuous, stating that she was shy and her siblings were outgoing and confident with whom she could not compete. She described herself as a shy person and unconfident person and troubled that people would not like her if she was not amusing and confident. She stated significant indications of social phobia and reported that she found difficult to make friends or having a conversation with strangers. At the start of her college program, about 5 months to her new class she could not make any friends. She reported further that she wanted to be an active member amongst her family members and friends but does not feel like achieving success. Maria was single reported that she liked her cousin until he mocked her in front of her other cousins being in a relationship with her. Nevertheless, she stated a strong desire of marriage and quoted her religion and family’s encouraging words of getting married earlier. Her family members consisted of her parents and her siblings including 4 brothers and 2 sisters. Her siblings were studying and some were settled in careers. Maria was particularly close with her eldest brother, while stayed distant with the rest of her family. She described her upbringing as “typical, except for my father”. She grew up in a joint family with her mother and siblings and her father resides at Dubai for his employment and visited intermittently and for short durations. She described her mother as slightly loving person but felt distant with her father because of distant relations. Her paternal side was conservative but her maternal side was quite open minded and modern. Her paternal side especially her father did not approve of girls studying or hanging out on their own. His parents were never too close or not too distant as she said that there was a fissure between them which she could not name. She described her father as a person who needed help and selfish. Overall, familial relationships seemed difficult.

Literature Review

Assessment and methods

At the beginning of therapeutic process, counseling Psychologist’s assessment of Maria based on initial assessment and presenting complaints which was social anxiety and social phobia. Her religion and religious cast was significantly important to her that she quoted and justified all her reasoning through religion. Similarly, her family provided slight financial support, but little emotional and social support. Maria seemed to be isolated and described herself as lonely, isolated and an anxious person who sought consolation and emotional support from others without stating her needs and with hope to found none, not even in the therapeutic process and counseling relationship.

From attachment perspective, Maria appeared to have characteristics of both dismissing and preoccupied attachment styles. Dismissive attachment is described as an emotional repudiation of central relations. Also a client with dismissive attachment is possibly to model their parents, but could be unable to provide explanations which provide assistance to their modeling [7,13,14]. Preoccupied attachment is classified as preoccupation with former attachment relationships. Also a client with this attachment style is possibly to appear passive aggressive or fearful while discussing their significant childhood relationships and to express in intertwined or markedly ambiguous sentences. The clients’ narratives in counseling process are usually the indication of their attachment styles [15-17].

During sessions, Maria’s narratives showed signs of preoccupied attachment in regard to her father. She was angry at her mother, whose embarrassment seemed to set the basis of her anxiety in young age and her father whose absence in their lives left her with lack of parental caregiving. That described anger at her father and mother was narrated by the client in a very confined and equivocal account. Particulars of those accounts were challenging to explore as Maria often ended her ambiguous statements about her feelings by drifting off into long unrelated sentences denying and delving into different incidents. However, she stated that she had relatively closer connection to her mother without providing much examples of her mother’s warming behavior towards her. Maria often communicated in sessions through ambivalence about conveying her distress, distinctive of dismissing attachment style. She embellished in ample discussion of her negative views of herself and articulated little optimism for the prospect of attainment of support through family, friend or counseling process. She expressed her struggle in feeling other emotions but anxiety in her life apart from the therapeutic sessions. Her midpoint narrative in a counseling session:

M: Sometimes I feel afraid that, I am so unsure but I would not call this feeling as nonexistence of faith, that things might (pause) might not or may turn out as magnificently as I imagine of just like other people. Or maybe if I say that that’s so implausible (pause) you know, you could dream it, but would you really expect that happening, if I say no, then maybe the likelihood of it happening just gets down. And then, a part of me also says, even if (pause), I think that goal of my life is to get married if not my cousin or anyone (small nervous chuckle). But, I actually want to live a contented life and a joyful family, so, I want that to be a foundation of (pause) I know that it will be a cradle of both bliss and stumbles, but I want the actions to balance the negative attitudes. I don’t want to be the most unhappy, unconfident, shy person, I don’t want melancholy in my children or (pause) um, (pause) I’d rather stay single and like (pause) or yes I guess I’d rather stay single and yearning for marriage rather than getting married and dejected with just a dreadful state.

T: Do these appear to be the most probable possibilities at this moment?

M: Yeah (pause) maybe, I am un-sure, I might (pause) the single element that I’d like to transform the most in my life is, just this anxious feeling of even trying and actually not feel terrible. And this is really, this is what worries me a lot, just even (pause) I mean, it’s not even rational. I’m giving all my confidence‘, ‘I want to be able to have a conversation with you’’ and although (pause) rationally and practically, I could make the list and say, I could even convince myself first, logically, that I could if not much then give a try. But emotionally, it’s too just hard. It’s (pause) I am not sure, it’s so intimidating I’m unwilling to take.

T: It seems like it scares you just too much.

M: (nods).

Characteristics of preoccupied attachment style, Maria seeks close and intimate relationships but stayed worried that these relationships might not be plausible and she would be distressed and lonely like her previous experience. Her worries about the readiness and trustworthiness of others offer an insight as to the features of her early relationships. In terms of attachment theory, the theory theorizes ‘‘the prime purpose of the infants and young children’s intuitive reactions, in man as in other animals, is to warrant vicinity to the adult, which is indispensible to survival. Crying, sucking, clinging, following, and smiling are all instinctual responses that eventually coalescing to form the broad mosaic of attachment behavior.’’ [2]. Founder of attachment theory Bowlby stressed that crying and smiling do not acted as the bridge to attach the child to the parent, but rather serve as a channel to attach the parent to the child. Crying and smiling to the mother indicated that the child might be wet, hungry, thirsty, startled, or emotionally deprived [2].

As Bowlby suggested, if, the objective of these infant’s behavior is to draw the parent to the child, what might Maria’s experiences have been with her physically distant father and emotionally distant mother? Is it probable that her crying was gratified by her mother picking her up, or be attentive to her needs and wants? As Maria’s generally restrained and anxious behaviors as an adult, it seems uncertain that she enjoyed an engaging, warm, and connected relationship with her mother or even father when she was an infant. It seems more plausible that Maria being an infant or young child was often left to soothe herself alone and it also seems like she was unsuccessful at this because a young adult, Maria had developed her personal self-soothing behaviors. For Maria, reminders of her important relationships did not offer her with comfort or support, a hint of an insecure attachment pattern.

Moreover, Maria narrated to lose hope that anyone could be able to help her, comfort her and provide a reliable presence. Bowlby stressed that human babies cry in need of assurance of proximity from a caregiver. And when Maria cried, she did not seem to expect that anyone could come to attend her needs. Sit seemed as if she had learned from her emotionally distant mother and absent father that her crying would not draw caregiver’s proximity and that her distress required to be controlled on her own. Maria appeared to have carried these expectations with her since childhood to her adulthood. Maria, the adult, as reported seemed to have thought that her emotional needs were irrational. She had taught herself as a child that it was better not to sought gratification of her needs from her parents or others. Her absent father was futile in provision of the kind of attending, compassionate relationship which Maria, needed for a child. The adult Maria found challenging in trusting that someone could provide that connection when she cried or seek relationships. She had difficulty in trusting and expecting, because she had not experienced that trustworthiness and attending emotionality from anyone. Such insignificant expectations subsidized to her devastating feelings of social anxiety and social phobia.

From Bowlby’s perspective, Maria’s current anxiety could be linked to her early familial relationships, which left her feelings unconnected to connect with others. Still, Maria struggled with the idea of viewing herself as a victim of relationships.

The resulting counseling session excerpt demonstrates this stance:

T: It seems like as if you’re trying to apprehend why this is happening to you.

M: I can’t want to bring myself in front of anyone, I don’t (pause) I don’t want to feel like I’m somewhat a victim, I don’t want to construct myself out to be like some sort of victim, I don’t want to feel as if I’m being offended. I sometimes feel like it’s the only reality. I could be angry at my parents. And that someone would have mistreated me. But I don’t actually feel like anyone has offended me.

It is clear from Maria’s statement that she did not want to see herself as a helpless person. Maria struggled seeing herself as a child who had been unhappy and needed soothing still. It can be inferred that she learned that it was not safe with her mother to be the wronged party, the infant who needed changing. Retreating from her needs, Maria’s mother sent the message to her daughter that her own needs were primary and Maria needed to take care for herself. More researchers, Beebe, Lachmann, and Jaffe (1997) debated that, between the child and the caregiver, primary interaction structures of the infant with caregivers indicate an imperative base for developing self and object representations [18]. They define ‘interaction structures’ as distinctive arrangements of the ways a mother and a child influence each other, outlines of the ways the contact develops [18]. Beebe et al. (1997) defined that, as these interaction structures reappear and become comprehensive patterns and started beginning of infant’s experiences [18]. Maria and her mother established childhood interaction patterns which strengthened the meaning that Maria’s mother was inadequate to be there for her needs, which Maria felt and learn to cry and soothe alone. Maria’s anxious feelings comprised of emotional state of hopelessness, her outlook that relationships with others were feeble, and her conflict to seeing others as reliable sources of meaningful connection: all these adult emotions sustained the conception that Maria the infant learned she would always have to adjust to her mother and not otherwise. And hence she taught herself that people could not rely upon for her emotional support or meaningful connection.

The single case study design A-B-A was employed. The data was collected from a single participant from a local college. Case was presented in the case conference before and after the employment of assessment and intervention techniques.

Results and Discussion

Demographic course of counseling process

Initially in therapeutic process with Maria, focus was on the release of her serious anxiety among everyone especially in groups or one-on-one interaction with opposite gender, by adopting eclectic treatments of relational and ego-supportive therapeutic approaches in individual integrative psychocounseling, along with adjunctive therapeutic support and counseling to focus on her social phobia and interpersonal issues. In the first few weeks of counseling, Maria became renovate on a treatment of basic stance in making conversation without being anxious. Maria’s confidence seems to be arisen. It is noteworthy that Maria appeared on every one of counseling appointments punctually and asked for follows up in case she needed help. Moreover, Maria never postpone or reschedule an appointment and neither did she skip any assignment/homework assigned to her.

The therapeutic relationship

At certain points in sessions, Maria seemed enthusiastic to please the counseling psychologist. When counseling psychologist’s explanations did not seem to fit with her internal experiences, she still did not disagree with her counseling psychologist. Later in counseling, Maria did seem angry at her counseling psychologist, the stand-in for her mother, although she had difficulty communicating this directly. Instead, she laughed uncomfortably as a habit, wanted to disagree with the counseling psychologist but reluctant to do this straight. However, as counseling process progressed, Maria improved in her ability to express feelings towards the counseling psychologist. The counseling psychologist encouraged her express her feelings or emotions in the present, but she still found that challenging to feel that it was safe outlet even in the therapeutic setting. Here the objective of counseling from attachment’s perspective was to provide her an atmosphere that nurtures attunement, and is confident enough “to cope with relevant protest” [12]. The counseling objectives were to provide a setting where Maria felt being understood, and also to make available a counseling process in which Maria’s appropriate and ‘‘relevant protests’’ discussed without holding back. In the framework of such settings, Maria’s attachment approaches could become more secure and her internal working model might initiate to alter.

Often, Maria played down the significance of the therapeutic relationship between counseling psychologist and the client. And this minimization of an important relationship is the distinctive feature of dismissive attachment style. Counseling psychologists see this minimizing in the subsequent therapeutic process excerpt, when counseling psychologist affirmed her relational growth. It was safe place for Maria to convince herself that the counseling psychologist does not care for her needs; then, if she lost her, it would not mean enough to hurt her. Such style of thinking is characteristic of dismissive attachment in which young ones have learned that connections and relationships cannot be trusted for emotional presence. As counseling process progressed and Maria’s anxiety lessened, she became more animated and engaged. The therapeutic relationship in counseling process, difficult to see evolving, became clearly compact which made counseling psychologist feel more engaging. At the medium of therapeutic treatment, Maria started to identify and show her own anger, something which was unreachable to her at the start of counseling. In the ending sessions, Maria instigated to display directly her feelings regarding the therapeutic relationship. She was also able to narrate, although in somewhat vague sentences, that she trusted her counseling psychologist. Such confidence is typical in secure attachment relationships, but had been unaccustomed to Maria in former relationships. Maria’s opinion of this flourishing trust and confidence in the therapeutic relationship provides intimation to the counseling psychologist that she was starting to dispense more secure attachment approaches.

Sable described, the working model of therapeutic relationship in due course wields supremacy over upsetting experiences and models of the earlier, opposing the client’s image of oneself as un-endearing and undeserving of secure affection relations [10]. Maria began counseling deeply anxious, with long-held beliefs about her worthlessness as a person and her un-lovability. Throughout counseling process, her preoccupied and dismissive strategies gradually offered a path to more secure attachment approaches, which included retrieving and communicating a range of positive and negative feelings to the counseling psychologist and to others. This unassuming communication of feelings showed Maria’s progress in having confidence that her relationships finally would be attentive and listens to her emotions. Given her history with caregivers, such relational growth was rewarding to see and was likely contributing towards her decreasing anxiety symptoms. It was the counseling psychologist’s therapeutic objective that an introject of the counseling psychologist as an observant and connected listener was a part of Maria’s internal world following counseling process.

Conclusion

The case of Maria demonstrates the implication of John Bowlby’s attachment theory to therapeutic work with adults from anxiety symptoms. At the start of counseling, Maria was a young female experiencing serious feeling of panic, isolation and physical symptoms. Suffering from signs of both major anxiety and social phobia, she had a vastly confined world into which few people entered. In Maria’s world, neither family nor friends could be trusted when she needed them and all relationships were questionable and question to change without explanation. Through the understanding of attachment theory, it seems that Maria’s internal working model was established from her attachments with childhood caregivers. Maria experienced her father as only absent figure and emotionally unsupportive. Maria’s mother, a person with discrepancies, sent the message to Maria that she could not be contingent on her warmly. Maria learned in her childhood that her mother’s needs were more imminent than her and that she could not be depended upon to help solve her problems.

Maria’s learned approaches for connection with others, including preoccupied and dismissing strategies, assisted her ineffectively as an adult and contributed to her social isolation and anxious symptoms. As an adult, Maria attempted to soothe herself with little success. She even attempted to use the religion as an adjunct parent, as a consultant on which she could depend, but she seemed to find little consolation there. From an attachment theory perspective, her anxiety indicators stemmed from her relational seclusion and anxiousness. The counseling process then was focused on developing a restorative attachment relationship with Maria where she would begin to experience and could rely upon an attuned, attentive, and caring others [10]. During the progress of counseling process, Maria learned to trust the counseling psychologist as an available other and learned to have reliance in the relationships. Maria’s corrective emotional experience in counseling process likely assisted to reassure her to hope and to seek meaningful connection in relationships in which her needs could be met.

Maria’s case demonstrates how adult attachment strategies are connected in history and in therapeutic intervention. The case also draws a connection between the attachment theory and anxiety, showing how relational isolation and panic contributes to adult anxiety symptomatology. The perspective of attachment theory allows in considering the counseling process of adult anxiety a new way. That discussion of counseling process with Maria, using the viewpoint of attachment theory to understand this work together, clearly demonstrates the strengths of this theory in applied counseling process.

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