Attachment, Relational-Needs, and Psychotherapeutic Presence

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 relationalneeds

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.

Attachment

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 subsymbolic,

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-andnow.

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.

Relational-Needs

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).

Psychotherapeutic Presence.

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.

References

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Abstract

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 relationalneeds