This article is a therapist review of the process that occurred during a systematic case study of
psychotherapy with Martha, a female client who presented with depression, anxiety, alexithymia and dismissive/avoidant attachment style. Assessment, diagnosis of the client and treatment direction is described, followed by a detailed account of the therapeutic process through 12 sessions and 2 post therapy interviews. Analysis team results are summarised, indicating support for the therapist’s identification of issues during the process of the therapy.
Particular attention is paid by the analysis team two points of rupture and repair, with pragmatic evaluation confirming that the relational struggles between therapist and client seemed pivotal in generating positive change.
Key words Avoidant Attachment Style, Dismissive Attachment Style,
Relational Transactional Analysis Psychotherapy,
Systematic Case Study, Hermeneutic Single Case
Efficacy Design, Systematic Case Study, Alexithymia
The following is based on a case study of ‘Martha’ (not her real name), a self-referred client in her late sixties, who was seen in private practice for short-term weekly psychotherapy (twelve sessions).
This is a process-orientated report of therapy, by the therapist, in which the focus is to make sense of the dynamics of the therapeutic relationship by tracking the points of rupture and repair (Safran, Muran & EubanksCarter, 2011) with Martha, a client whose life position is I’m not OK- You’re not OK (Ernst, 1971) and who appeared to have a dismissive/avoidant attachment pattern (Wallin, 2007).
For a therapist working from a two-person, relational perspective, with its emphasis on mutuality and bidirectionality, clients such as Martha represent a challenge. Typically clients with a dismissive/avoidant attachment style are:
- cut-off from their own feelings, thoughts or desires and from others (rigid internal and external boundaries)
- have a limited capacity to symbolise and typically manifest their distress as physical symptoms (Leader & Corfield, 2008)
- dismiss the importance of their own history and the influence of parental figures in their emotional development
- avoid psychological closeness – Don’t be close injunction (Goulding & Goulding, 1976)
- constrict feeling – Don’t feel injunction (Goulding & Goulding, 1976)
- diminish the importance of others and are reluctant to let the therapist matter to them
- believe that ‘all is well’ but their physiological response indicates otherwise
Wallin suggests that working with such clients requires that the therapist “… balance empathic attunement with confrontation. Usually patients need the former to feel that we understand them. Often the dismissing patient, in particular, needs the latter in order to feel that we exist that we can have an impact on him and they can have an impact on us” (Wallin, 2007, p. 212)
This case study shows the therapist’s struggle to perform this delicate balancing act, in her attempt to reach Martha in a meaningful way and to acknowledge the impact that they had on each other, so that Martha could begin to formulate her experience.
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