Clinical Social Work Journal, Vol. 33, No.

1, Spring 2005 ( 2005)

DOI: 10.1007/s10615-005-2619-z

SOME CLINICAL APPLICATIONS

OF ATTACHMENT THEORY IN ADULT
PSYCHOTHERAPY
Cynthia J. Shilkret, Ph.D.1

ABSTRACT: This paper discusses the usefulness of attachment

theory in working with adults in psychotherapy. There are four classifications of attachment status in adults: secure attachment, and three
types of insecure attachment: dismissing, preoccupied, and disorganized. These categories do not conform to standard diagnostic entities.
I discuss examples of the three insecure attachment categories and the
likely transference and countertransference configurations that may
occur in each category. These categories provide an additional way for
therapists to understand and to respond to the needs of their clients.
KEY WORDS: attachment; psychotherapy; diagnosis; transference; countertransference.

INTRODUCTION
Therapists are constantly striving to improve their ability to help
the people with whom they work. One way they do this is by trying to
improve their diagnostic skills so that they understand what their clients are dealing with and how they can be maximally helpful. In addition to traditional diagnostic categories, another way of assessing
clients that can be very useful to clinicians comes from attachment
1
Correspondence should be directed to Cynthia J. Shilkret, Ph.D., 7 Hadley Street,
South Hadley, Massachusetts 01075; e-mail: cshilkret@comcast.net.

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2005 Springer Science+Business Media, Inc.

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theory. In this paper I present a brief description of attachment theory

and how it can be helpful in understanding clinical material. I then
use case examples to illustrate three attachment categories and the
transference and countertransference elements that are typical of each
category.

OVERVIEW OF ATTACHMENT THEORY

Attachment theory is a theory of human motivation formulated by
John Bowlby and elaborated by Mary Ainsworth that emphasizes the
importance of the childs tie to the mother and the consequences of the
disruption of that tie (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1969, 1973, 1980). It incorporates concepts from ethology, developmental psychology, and psychoanalysis. Bowlby, as a result of his
clinical work at a school for maladjusted children and his observational
research documenting the intense upset of hospitalized children,
hypothesized that infant behaviors such as sucking, clinging, crying,
smiling, etc., further attachment to an adult caregiver, which serves to
protect the infant from danger. While Bowlbys original focus was on
the attachment behavioral system, he also was interested in the impact
of attachment behaviors on the inner world of the child. Bowlby proposed the concept of the internal working model, which included the
persons internal representations of self and attachment figures. The
child develops these representations through interactions with the
important caregivers in the childs life. The internal working model
allows the child to predict the behavior of the attachment figure so the
child can plan his responses so as to maximize the attachment. This is
important because interruptions in the tie to the parent are profoundly
disturbing to the child.
Ainsworth further developed attachment theory with her empirical
studies of motherinfant attachment. She observed mothers and
infants at home, first in Uganda and then in Baltimore (Ainsworth,
1963, 1967; Ainsworth et al., 1978). She noted striking differences in
the sensitivity of mothers to the signals of their infants. To study the
differences in these interactions in more detail she developed a laboratory procedure called the Strange Situation (Ainsworth & Wittig,
1969). It is a 20 min study in which 1-year-old infants are observed
under a variety of conditions: first with their mothers, then with a
strange woman, then alone. The mother leaves briefly and returns
twice. The procedure provides several opportunities to observe the
infants reactions to being left and reunited with the mother. Ainsworth found that approximately 65% of infants were rated securely

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attached. They protested the mothers leaving, greeted her warmly

when she returned, and sought to be near her.
However, Ainsworth noted two other categories of attachment,
which she labeled avoidant and ambivalent. Avoidant infants did not
protest when the mother left. They explored the environment, were
friendly to the stranger, and appeared quite independent to an outsider. But they also did not immediately acknowledge the mother when
she returned. They would avert their gaze and move away from her.
Later studies also noted that while they appeared unbothered, their
heart rates showed an arousal pattern similar to those of more overtly
distressed infants (Fox & Card, 1999). Ambivalent infants demonstrated an alternately clingy and angry resistance to contact. There
was overt distress when the mother left, and contactseeking when she
returned, but it was mixed with direct or displaced anger and a failure
to be fully comforted by her (For a more detailed description of the
work of Bowlby and Ainsworth, see Bretherton, 1992).
Mary Main, who was a student of Ainsworths, continued the
development of attachment theory. Main (1995) hypothesized that the
three attachment styles are organized strategies that infants learn to
maximize contact with their specific parent. For example, to enhance
the relationship with a mother who does not like dependency, an infant
may develop an avoidant attachment style, appearing to be very independent. Subsequently, Main and her collaborators added another
attachment category, disorganized/disoriented, for the small group of
infants who did not fit in the first three categories (Hesse & Main,
2000). These infants showed disorganized or idiosyncratic patterns of
interaction with their mothers. For example, some would freeze or
appear to move in slow motion, some appeared frightened of the parent, while others showed contradictory behavior patterns.
Based on Bowlbys concept of the internal working model, some
current attachment researchers have focused on the internal representations of attachment and the consequences of those representations.
Main and her collaborators have studied these representations in the
attachment styles of adults. They developed the Adult Attachment
Interview (AAI), a semistructured interview in which parents were
asked to reflect on their early experiences with their own parents
(Main, 2000), Main identified four adult attachment categories: secure,
dismissing, preoccupied, and unresolved/disorganized. Secure adults
were consistent, clear, and relatively succinct in their interviews. If
they had traumatic histories they were able to discuss them
in a selfreflective manner. Dismissing adults gave responses that
minimized the importance of attachmentrelated experiences. Their
responses were often superficial and contradictory. Preoccupied adults

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showed a confused, either angry or passive, preoccupation with attachment figures. Their interviews tended to be long and unclear. Unresolved/disorganized adults exhibited brief episodes of extreme
disorganization when discussing specific traumatic events, although
the rest of their interview might be categorized in one of the other
attachment styles. Research has demonstrated a significant intergenerational transmission of attachment style (Main, 2000). There is a high
correlation between the attachment patterns of parents and their children, independent of the temperament of the infant. Secure parents
are highly likely to have secure children, while dismissing parents usually have avoidant children, preoccupied parents tend to have resistant
children, and parents categorized as unresolved/disorganized have children categorized as disorganized/disoriented.
Because attachment styles represent a pattern of interaction that
individuals have learned to enhance their connection to a parent and,
by generalization to other authority figures, it is reasonable to assume
that clients will demonstrate their attachment styles in the therapeutic
relationship. Therefore, the transference should reflect the clients
attachment category, and the therapist should be able to discern the
category and use it to further the therapy. Recent clinical research has
focused on the disorganized category, especially since these individuals
are highly likely to have been maltreated as children and to have significant trauma histories (Lyons-Ruth & Jacobvitz, 1999). Current clinical researchers are investigating the link between disorganized
attachment and dissociative disorders (Liotti, 1995) and borderline personality disorder (Fonagy, 2000). Despite case reports that discuss
attachment disorders connected to a variety of symptom patterns. (e.g.,
Fish, 1996; Fish & Dudas, 1999; Sable, 1992), no significant correlation
has yet been found between diagnosis and attachment status (van
IJzendoorn & BakermansKranenburg, 1996). Therefore, clinicians
need to consider attachment status independent of the diagnosis of the
client. The following clinical vignettes present examples of the three
insecure attachment categories and some implications for treatment.

DISMISSING ATTACHMENT
These individuals attempt to minimize the importance of attachmentrelated experiences. In therapy they often use minimization and
denial to deal with their conflicts and affects. They may minimize the
effects of their history, minimize the importance of the therapists comments, or insist they have no feelings about breaks in the therapy,
such as vacations or termination. As a result, therapists treating

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clients with a dismissing style may have feelings of being unimportant

or even being ridiculed. One common countertransference reaction to
these clients is to believe that they really do not care about the therapy
and to allow them to terminate prematurely. These clients often limit
their treatment to shortterm therapy because they mistake defensive
selfsufficiency for true independence.

Alan
Alan maintained an amused attitude throughout his 5 year therapy.
He entered therapy in his mid30s because his wife threatened to leave
him if he did not stop his constant womanizing. They had been married for
many years and although he was often disdainful of her, for example, insisting that she was not his intellectual equal, he was very upset at her threat
to divorce him. He was the younger of two children. He insisted that his
early life had been great. He did what he wanted with no interference
from anyone. He acknowledged that his mother could be very critical of people, including him, but he said that he had gotten over that years ago, and
it no longer bothered him. Alan was a successful businessman and often
cancelled sessions because something more important had come up. Not
surprisingly, he reported with pride his sons insistence on doing things
independently from a very young age.
It took a year of therapy before Alan could acknowledge any painful feelings. Early in the therapy if any attempt was made to discuss his apparent
lack of reaction to interpersonal difficulties, he insisted that these things did
not bother him. He often cancelled sessions when he was having a serious
problem, and I would not hear about it until he had resolved it himself. He
tried to end therapy several times, insisting, things were fine now. His
transference attitude that the therapy was unimportant stimulated a countertransference response, to point out how important the therapy really was
in his life. However, I learned not to press him about affective issues
because he felt that I was just trying to weaken or shame him. My capacity
to remain a consistent attachment figure for him (i.e., I behaved as if the
therapy relationship was important no matter what he did) while letting
him regulate his closeness to me allowed him to make slow but steady progress. He stopped having affairs and was able to enjoy his relationship with
his wife. He became able to cooperate with colleagues, and his business
improved. He eventually was able to discuss his extreme disappointment in
his parents. He cried when he discussed how painful it was that his father
could not or would not shield him from his mothers demeaning tirades and
criticisms of him.
After 5 years he announced that he was ready to end his therapy. I agreed
and suggested that we spend a few sessions reviewing the therapy and discussing the termination. He acted amazed, insisted that there was nothing to discuss, that he had no thoughts or feelings about ending, and that he would not
return for even a single session. The therapy ended at that point. However,
when he sent me his final payment he enclosed a brief note thanking me for
my help and, as was characteristic of him, making a joke about therapy and
therapists.

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Danielle
Danielle was a married businesswoman in her 40 s who entered therapy
because she could not decide whether or not to divorce her husband. She
presented it as if it should be a simple businesslike decision and did not
understand why it was so difficult for her. They had not been getting along
for some time, he was drinking too much, and yet she could not make a
decision. Danielle reported a difficult childhood, but minimized the impact
on her. Her parents had fought and ultimately divorced, and as the oldest
of three children she took on a lot of responsibilities at home. Her mother
was never satisfied with her, but Danielle insisted that she had dealt with
that by limiting her contact with her mother so that it was not an issue for
her. She did not intend to spend much time in therapy; she figured that a
few sessions should be enough. When I asked about her feelings about getting a divorce she seemed puzzled and said she did not understand what I
was saying. Of course she would feel sad if they divorced, but she would
cope with that. She just wanted some help in making the decision. When I
suggested that her early history might have an impact on her current situation, she dutifully answered my questions about her family, but she could
not see any connections.
I felt shut out and unsure of how I was going to reach this woman. I
focused on her feeling of paralysis, that she could not make a decision, and
asked if she had any thoughts about that. She slowly began to recognize that it
was connected to her fear of making a mistake. She also began to see that she
had the same problem at work. She felt compelled to make fast decisions
because if she took the time to think things over, she might become worried
about making a mistake, and then she would be unable to make any decision.
In fact, this had caused some problems in her job, which she also wanted to
resolve. As we discussed this, she began to connect her fear of making a mistake with her mothers constant criticism of her. When I was not deterred by
her repeated comment that these discussions were not helpful, but instead
tried to explore what discussing her problems meant to her, she became less
fearful that having a relationship with me would result in my criticizing her.
At that point she decided that she would continue in therapy until she completely understood all her feelings about getting a divorce, no matter how long
it might take.

Alan and Danielle demonstrated similar attachment issues,

although they would be viewed differently using a more traditional
diagnostic framework. Alan clearly presented severe narcissistic
pathology, while Danielle exhibited an obsessional character style,
but both worked hard to minimize any overt attachment to the therapist. Alan used frequent missed appointments, and Danielle used a
hyperrational, unemotional approach to therapy, but both denied
any strong feelings about the therapy. Because of the clients dismissing style, there was the pull to be dismissing in response (which
could take the form of allowing the therapy to end prematurely), or
to try to force the client to recognize the importance of the therapy
(by premature interpretations).

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PREOCCUPIED ATTACHMENT
These individuals exhibit a confused, either angry or passive,
preoccupation with attachment figures. Their AAI interviews tend to
be very long and unclear, as if the interview questions stimulated
memories which interfered with the persons focusing (Main, 2000).
In therapy they often demonstrate a confused preoccupation both
with attachment figures in their past and with the therapist. They
may brood over what the therapist really meant and alternate
between being angry with the therapist and pleading for help. Some
clients are overt about their preoccupation with the therapist (for
example, calling frequently between sessions), while others keep it
hidden (for example, keeping a journal in which they write about
the therapist, but never mention it in therapy). Preoccupied clients
can often leave the therapist feeling frustrated and worried, as they
alternate between asking for help and rejecting any help that is
offered.
Barbara
Barbara was a married woman in her 40s with three grown daughters
who entered therapy because she was profoundly depressed. Although she had
been depressed for most of her life, her depression had recently intensified following the illness of her husband, and she obsessed about committing suicide.
Although her husband and daughters insisted they loved her, she could not let
herself believe it, and she ruminated on their true feelings for her. Any act of
normal independence by one of her daughters (for example, a small disagreement about when Barbara and her husband would visit the daughter), would
leave Barbara searching for signs that her daughter really did not want her
around. Yet she could never actively inquire about her daughters feelings;
instead she would passively brood about her mistreatment. Barbaras early life
had been quite difficult. Her father was an abusive man who openly preferred
her brother to her. Her mother was a very fearful and dependent woman. Barbaras mother alternately clung to her and neglected her (by not protecting her
from her father and brother).
In therapy she became secretly preoccupied with me. She insisted she did
not care about me or about the therapy. However, she paid extremely close
attention to everything I said and did, attempting to figure out my real
thoughts and feelings about her. Often, her announced wish to end therapy
would follow an interaction in which she became convinced that I did not like
her and I wanted to get rid of her (I would only learn this weeks or sometimes
months later, after I had vigorously demonstrated that I did not want her to
leave therapy). Several months into the therapy, she revealed with some
embarrassment that in discussions with her husband she referred to me, not
by my name, but by a unique term for therapist that she had made up (similar
to the word shrink). Interestingly, it was ambiguous and could have been
taken as either positive or negative.

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I was concerned about her, but as I maintained a consistent positive attitude

toward her, she became more able to discuss her confused feelings about her
parents and especially her mother. She was preoccupied with figuring out how
her parents really felt about her. Sometimes her mother acted in very loving
ways, but at other times she did not protect Barbara from her father or
brother. A turning point in the therapy came when Barbara was able to call
me when she became suicidally depressed, and I met with her for several extra
sessions until the crisis passed. She was then able to feel that, unlike her parents, I was not bothered by her wishes to depend on me, and she began to analyze her relationship with her parents in a deeper way. As she came to
understand that she did not cause their mistreatment of her, she became less
preoccupied with their view of her and less depressed in her current life.

Edna
Edna entered therapy like a whirlwind. She was a married woman in her
40s who began therapy because she had fallen in love with another man and
could not decide whether or not to leave her husband. She was the child of
immigrants who had a volatile relationship. Her parents fought constantly, and
Edna and her brother were often drawn into their battles. Her mother alternated between being overly involved in her life and being rejecting. Edna had
numerous memories of her mother acting helpless and demanding that Edna
do things with her, only to have the event end with her mother criticizing the
way Edna did things. Edna would then become either tearful or angry or both.
Edna would come into her sessions with a definite agenda and state that she
wanted to focus on her marriage, but she would then spend the session railing
against her parents or fantasizing about the new man in her life (Despite her
frequent discussions of him, it was not clear to me for quite a while if he actually was interested in her). She had great difficulty seeing any connections
between her marriage and her relationship with her parents or their relationship with each other. When the other man made it clear to her that he was not
interested in a relationship with her, she quickly became enamored of another
man and resumed her fantasizing.
Edna would ignore my attempts to discuss these issues with her, but then
would accuse me of not helping her. She would complain bitterly about the
therapy but had trouble recognizing that these were the same kinds of complaints she voiced about her parents. Her complaints would often be followed
by urgent phone calls to me during which she insisted that I tell her what to
do about a recent argument with her husband/son/mother, etc. I would often
feel burdened and overwhelmed after sessions or phone calls with her. As a
result of her mothers insistent helplessness, Edna unconsciously believed that
people were weak and could not manage without her help. Therefore, she felt
she had to worry about her husband, son, and fantasied love interest. During
the course of the therapy I repeatedly pointed out her preoccupation and worry
about others. As she became aware of her pattern of worry about others followed by criticism of them and then disengagement, she became better able to
limit her overinvolvement. She also became increasingly able to see that this
had been the pattern of her relationship with her mother.

Standard diagnostic categories would view Barbara and Edna quite

differently. Barbara suffered from a major depressive disorder of long-

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standing, while Edna exhibited characteristics of a histrionic personality disorder. However, both of them demonstrated a preoccupied
attachment style characterized by an intense involvement with their
mothers and, through the transference, with the therapist. Barbaras
involvement was a secret, unspoken one, while Edna was more
overtly demanding, as each one replicated the specific kind of preoccupied attachment she had with her mother, but both of them generated
strong feelings in me. I wanted to help them, yet I felt frustrated that
my efforts were not good enough. In that way, I became preoccupied
with them, which is a countertransference danger in treating clients
with a preoccupied attachment style.

UNRESOLVED/DISORGANIZED ATTACHMENT
These individuals have not found a consistent attachment style to
allow them to resolve early traumas of attachment. They often report a
history of severe maltreatment that may include abuse (sexual or physical) or neglect. In some families, there is no abuse but rather an unusual pattern of the parent appearing to be afraid of the child (Hesse &
Main, 2000). Because the person to whom the child should turn for
comfort is the very person who frightens the child (either by overt
abuse or by appearing frightened, i.e., not dependable), these children
are caught in a situation in which they cannot develop an organized
attachment style to satisfy their attachment needs. When interviewed
as adults, they are disorganized when traumas involving relationships
are discussed, but they may show one of the other attachment styles at
other times. Therefore, they are often given two attachment ratings
(e.g., disorganized/dismissing or disorganized/preoccupied). In therapy,
they often intensely worry and confuse the therapist as they move
between different symptoms, different affective states, and different
states of consciousness without any seeming predictability.
Carol
Carol was a very attractive married woman in her 30s who entered therapy because of a fear of vomiting, and a corresponding preoccupation with what
she ate (to insure that she only ate good food that would not make her sick).
While her initial presentation was organized and coherent, she did appear to
be preoccupied with her parents and still upset about decisions that they had
made years ago. For example, she attended the college that they preferred,
rather than one that she preferred; she ruminated over every criticism of her
no matter how minor; and she worried that she was not living up to the standards of her church. This was part of her general pattern of being a good girl

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and never being rebellious. I assessed her as having a preoccupied attachment

style. However, after a few sessions she revealed that in adolescence she had
been sexually molested by a family friend. She then became suicidal and was
hospitalized briefly. Over the next few years she developed other serious symptoms including anorexia, bulimia, delicate selfcutting, panic attacks, and
severe mood swings. During this time many different medications were tried to
little effect, and she was hospitalized several more times.
I never knew which aspect of herself Carol would present to me. A good session, in which she was calm and competent could be followed by a session in
which she was panicky and begging me to help her, or one in which she was
very depressed and resigned to never improving. I felt that there was little consistency in our relationship, and I became worried about my ability to help her.
However, I then realized that my worry was part of a countertransference reaction to her disorganized symptom picture. When I remained concerned but not
overwhelmed, over the course of several years she became increasingly able to
discuss her early history including several vignettes in which one or both of
her parents had behaved very erratically, sometimes frightening her, which
they then denied. My capacity to remain calm in the face of her affect storms
and shifting symptoms allowed her explore the unresolved traumas in her history. Unlike her parents, I did not frighten her with erratic behavior, nor did I
appear afraid of her. She was then able to begin to form a secure attachment
to me and a more consistent and organized way of relating to other people.

Frances
Frances was a successful professional woman in her 40 s who came into
therapy because she had been unable to sustain an intimate relationship with
a partner. She had been involved with both men and women, but no relationship had ever lasted. She reported her history in a clear, organized way but
without any affect. She was the oldest of three children, and her parents were
both very involved with their careers. But she insisted this had never been a
problem because the parents had sufficient money so that there was always a
hired caregiver in the home. She related to me in a respectful but distant way.
She had been in therapy before and had found it somewhat helpful, but she
could not tell me anything specific about her previous therapy, except that her
therapist had once fallen asleep during her session. Whenever I would try to
discuss any affects connected to incidents in her life (for example, how she felt
when her therapist had fallen asleep), she would insist that she had no particular feelings about it or that the feelings had been very minor. She discussed
her work, her friendships, and the events in her life in the same dry manner. I
initially viewed her as demonstrating a dismissing attachment style.
After the first few months of therapy, Frances began to show an extreme
reaction to my attempts to explore her thoughts or feelings about interactions
with people in her life, either past or present. She would report the interaction,
and when I asked her to elaborate, her speech would become slower and slower
until she appeared to be asleep. I would wait for her to wake up, and she would
then continue the session, but she would usually be unable to continue our previous discussion. Sometimes she did not remember the content, but even when
she did remember she would have no further thoughts about it. Often, as she
became sleepy, I would find myself becoming sleepy, too, and I would have to

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work hard to remember what we had been discussing. Once, when I pressed
her about the possible meaning of her sleepiness she remained awake, but then
had a frightening sensation of parts of her body changing size. I found myself
feeling alternately sleepy, confused, and extremely worried about what was
happening to her. Unlike Carol, she continued to function at a very high level
outside of the therapy and hospitalization was never a consideration.
As the therapy progressed, Frances very slowly became able to tolerate discussions of affectladen interactions with others. She eventually was able to
recall her early history. There was no evidence of abuse, but she had been
severely neglected psychologically. Her parents seemed to have little interest in
their children, leaving them alone for long periods of time with only the maid
for company. Frances, being the oldest, suffered the most, since her younger
siblings could turn to her for comfort. She was very frightened of the intensity
of her feelings, including the feelings that might emerge if she explored her
traumatic and psychologically bleak early life, and so she would shut them out
by falling asleep. Over many years in therapy Frances became increasingly
able to feel secure enough with me so that she could remember her traumatic
past and remain awake to discuss it.

Both Carol and Frances presented confusing diagnostic pictures.

During her many hospitalizations, Carol received multiple diagnoses,
including eating disorder, panic disorder, bipolar disorder, and borderline personality disorder. Frances fit many of the criteria of a dissociative disorder. However, they both demonstrated an inability to
maintain a consistent type of attachment in their relationship with me.
Their disorganized attachment style was reflected in their multiple
and severe symptoms, and in their difficulty finding comfort in their
relationships with others and with me. As a result, I often felt extremely worried about my ability to help these intensely suffering women.
These clients often leave their therapist feeling lost as they try to
understand a confusing symptom picture. I had to work very hard to
cope with my own confusion (at least in the beginning of therapy) and
to remain calm and clearheaded in the face of multiple symptoms,
intense affects, varying states of consciousness, and other crises.

DISCUSSION
Traditional diagnostic categories (e.g., DSM-IV, 1994) can be useful
because their clear criteria provide a shorthand way of understanding
clients problems. However these diagnostic categories themselves do
not address either the developmental histories of the clients or the
likely impact of the clients problems on the therapeutic relationship.
The brief vignettes of these six clients demonstrate the way in which
the categories of attachment theory can be helpful to both therapists
and clients. These categories can enhance the understanding of the

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transference relationship and the possible countertransference reactions that therapists might experience.
Attachment theory also sensitizes therapists to the kind of attachment the client can tolerate, at least at the beginning of treatment. For
example, the common problem of how to handle patient cancellations
can be examined to demonstrate the differences in technique that
might be required with different attachment styles. Clients with a dismissing attachment style are often unable to respond to a therapist
who tries to investigate the cancellation as a way of focusing on the
therapeutic relationship. For these clients, discussing the meaning of
the cancellation can be an upsetting experience since it implies that
there is a relationship worth discussing. The more the therapist tries
to focus on the issue, the less involved the client may seem to be. Both
Alan and Danielle gave clear indications when I had gone beyond the
degree of overt attachment they could tolerate. Characteristically, Alan
would make a joke and ridicule any comment about our relationship,
while Danielle would look blank and say that she did not understand
what I was trying to tell her. I learned not to spend much time trying
to discuss the meanings of their cancelled appointments.
In contrast, a therapist whose client displays a preoccupied attachment style will usually need to respond to cancellations differently.
Since these clients are preoccupied with the therapist and with the
mistreatment they have suffered in their early relationships, they
would be hurt and worried that the therapist did not like them if the
therapist did not try to explore the meaning of the cancellation, even if
it only resulted in the client complaining that the exploration was useless and that the therapist was not helpful. With disorganized clients,
close attention to the meaning of the cancelled sessions is also important to provide reassurance to the client that the therapist will remain
a consistent and steady object in the clients life no matter what the clients behavior. However, with disorganized clients the therapist also
has to take into consideration the secondary attachment category in
determining the appropriate therapeutic response. For example, I
always commented on Frances missed appointments (and there were
many of them), just to let her know that I was paying attention. However, since I viewed her as disorganized/dismissing, she could not focus
on the discussion for very long, and I did not expect her to. In contrast,
with Carol (disorganized/preoccupied) I would focus more actively on
the meaning of the sessions she missed.
It is an interesting question as to whether attachment styles can
change over time, and whether therapy can help in that process. It
may be that therapy can only help a person develop a more stable version of his or her preexisting attachment style. However, there is

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some evidence that attachment styles can change from insecure to

secure as a result of therapy. For example, Fonagy and his collaborators have found that after intensive psychotherapy 14 of 35 nonpsychotic clients changed their attachment classification from insecure to
secure (Fonagy, et al., 1995). Yet whether or not the attachment classification changes, the use of attachment theory provides an additional
way for therapists to understand and to further the therapeutic process.

ACKNOWLEDGMENT
I am grateful to Robert Shilkret, Ph.D., for his careful reading of
this manuscript and for his many helpful comments.

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Cynthia J. Shilkret, Ph.D.

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