No Strings Attached
In the iconic 1865 novel Alice in Wonderland, there is a scene in which several characters suddenly become wet. In an attempt to help everyone dry off, the dodo bird suggests that everyone should and run around a lake to dry off. This is an interesting kind of race, though: the dodo bird tracks neither the distance traveled nor the time taken by participants to run around the lake. Here, the end result is much more important than specific technical differences. When the other characters eagerly asked who had won the race, the dodo bird famously replied, “everybody has won, and all must have prizes.”
And as I go down the rabbit hole of psychotherapy (insert eyeroll here), I begin to think more like the dodo bird. Like this quirky fictional character, I have begun to look at change from a holistic perspective, rather than get bogged down in the specificity of my profession—therapeutic intervention. As I become a more confident and patient counselor, I become aware that change and positive outcomes are attributed more to the vulnerable person across from me and the collaboration we enter, and less to what I can impart on someone. When I first began counselling, I was so concerned about remembering specific open-ended questions I had learned in graduate school that I almost forgot about the importance of my work: my client.
Ironically, I was suffering from anxiety before seeing a client and almost scripting out sessions. I have started to understand that constructs like engagement, collaboration, relationship, and the therapeutic environment contribute more to growth than specific interventions learned at graduate school. In essence, when looking at different types of therapy, “everybody has won, and all must have prizes.”
Specific, empirically supported therapeutic interventions are vital when looking at achieving positive outcomes. Focusing too much on intervention can get in the way of more important aspects of engaging young adults in therapy. A common factors approach to psychotherapy found that positive outcomes can be attributed to four dynamics: extra therapeutic change (40%), an empathetic therapeutic relationship (30%), expectancy and power (15%), and individual therapeutic intervention (15%). These statistics do not suggest a lack of therapist skill or knowledge; it simply hones in on the skilled factors that do contribute to change. To be able to sit with your own discomfort in life as a therapist while providing a safe, caring, non-judgmental atmosphere is a skill. Moreover, being able to identify barriers to change, instill hope in others, give understanding and knowledge to psychological underpinnings, and often assess safety in others is skill. Most importantly, being able to engage those in therapy is one of the most vital skills therapists hope to possess.
Young adults can often be reluctant to engage in therapy because of experiences with vulnerability and distress early in life. Often, this can stem from disorganized or weak attachments we learn. The four primary attachment styles are: secure, insecure-avoidant, insecure-ambivalent, or disorganized attachment. A secure attachment is when a caregiver consistently meets our needs through sensitivity and attunement. This means that when we are in distress, our parents react to our distress, and we can trust that they will be consistently present to do so. An insecure-avoidant pattern occurs when the primary caregiver only meets some of our distress needs. Here, independence can develop quickly as the caregiver rejects our need to attach. Parents are often inconsistent with their responses, often ignore our distress, and cause considerable distress themselves with their own inability to handle our discomfort. An insecure-ambivalent style develops as a result of inconsistent caregiver behavior and experiences. We become too dependent on the caregiver and individual autonomy is compromised. Finally, a disorganized attachment is when our attachment with a caregiver is fractured as a result of trauma, which can cause a variety of interpersonal concerns. These early internal working models appear to have a direct effect on a young adult’s level of relational therapeutic engagement.
Young adults with a secure attachment base have adaptive interpersonal functioning and emotional adjustment. In one study, our “security of working models was related to seeking support from a close friend during a joint problem-solving task…whereas insecurity was associated with behaving more disruptively toward a friend when experiencing a negative emotional state.” In short, our early attachment patterns correlate with how we interact and engage in other interpersonal relationships later in life. Those with a secure attachment base are more willing and able to effectively talk about personal concerns, as well as their friends’ concerns. Young adults with an insecure attachment base may have difficulty with open communication and being able to be constructive around emotionally charged conversations. Later, these individuals may develop strategies focused at avoiding distress during personal interaction. Insecure attachment bases have also been connected to depressive symptoms and an inability to cope in stressful situations. During their formative years, these individuals may find interpersonal relationships to be difficult to cope with. It’s important to note here that just because our parents may not have demonstrated a strong, secure attachment, it doesn’t mean they didn not love or care for us; they are not synonymous. I can give a personal example to highlight what I mean. When I was seventeen, I got into a very bad car accident. It was completely my fault, my car was totaled, and my younger brother almost died. Parents who would meet my distress with love, patience, comfort and understanding would reinforce a secure, healthy attachment. My parents responded with anger and blame. I was asked what was I thinking, how I could be so irresponsible, and heard very clearly how my dad’s insurance would skyrocket. My parents loved me, but they didn’t meet my distress in a way I needed. I learned (maybe re-learned), my parents might not meet my vulnerability and distress in ways that make me feel secure.
Research shows that there is good news. Insecure attachment styles are not fixed, and they can develop throughout adulthood. We have an ability to change, and development is never fixed.
Therapists can provide a replacement of old attachments styles and show young adults that they can engage in vulnerability, and that emotional vulnerability can look different. A counsellor can be a secure base from which clients can explore the world with safety and security. As a practicing therapist, therapy is often about showing people life can be different; relationships and vulnerability can look different, trust can look different, and growth and hope can look different. A secure attachment is formed the same way a caregiver would form a secure attachment with their child. In order to form this secure attachment, a therapeutic dyad must be filled with sensitivity, unconditional acceptance, and genuine curiosity. Responding to a client’s distress with non-judgement, safety, and acceptance are the same ways a therapist can form a secure attachment with clients.
Engaging young adults in the therapeutic process hinges on many different factors, perhaps none more important than the therapeutic alliance between therapist and client. A group of researchers looking at meaningful engagement concluded that developing strong therapeutic “relationships with young adults may facilitate engagement and lessen resistance to treatment by providing a stable, accepting and supportive context whiten which therapy may take place” This sounds strikingly similar to the conditions that a secure attachment base would encourage and foster. When looking at engagement of reluctant clients, one study found that therapists who consciously engaged in building alliances and rapport were much more likely to engage reluctant clients in therapy, resulting in a 93% success rate. This was compared to a 42% success rate when therapists did not focus on building alliances. It seems that if therapists learn different and unique ways of building alliances, they are more likely to engage reluctant clients in therapy and significant changes can occur. Also, those who have studied the working alliance closely concede that “any aspect of intervention that relates to engagement in purposive work contributes to the alliance.” Clients coming into therapy should expect to come to an environment where they want to engage. After all, they will be the ones doing the work to change and achieve outcomes. Our aim as therapists should be to create conditions that invite personal growth and reflection, and instill hope and motivation to do so. This only occurs if someone feels like they can engage in a secure relationship.
The purpose of this article, essentially, is to help you, the reader, view therapy from a more realistic lens. A client-counsellor relationship is like any other: if you don’t connect, you don’t trust, you don’t feel comfortable, and you will be less inclined to share your deepest worries and thoughts with the person across from you. An enormous part of finding success in therapy is simply feeling comfortable sharing with your therapist, and the relationship between therapist and client should start with establishing points of connection. Of course, some people who may benefit less from therapy, because they already have secure attachment to multiple people in their lives who are non-judgemental, empathetic, and who they can trust with our struggles. However, for those of you who feel like they lack trusting and secure relationships in their lives, regularly meeting a counselor may be of enormous help. It is important to give credit not only to the amount of academic study and practice that goes into the work of a counselor, but also to other factors that can create tangible change, such as a secure counselor-patient relationship. Hearing traumatic narratives and troubling behavior on a daily basis, while staying out of judgement, showing unconditional positive regard and empathy in light of difficult subject matter requires tremendous skill and effort. And of course, it is hard to put in effort if the therapist does not genuinely care for the patient, and vice versa.
Even in light of how important it is for you to form a trusting relationship with your therapist, remember that you already have it in you to grow and change, and the efficacy of therapy isn’t deep breathing or linking thoughts, feelings, and actions necessarily—it’s your innate ability to heal. That being said, your ability to engage in therapy, and thus grow, is inextricably linked to your therapeutic relationship. It’s the trust and hope you place in a counsellor, and the counsellor’s ability to provide the necessary conditions, that earn your trust and hope that helps your growth, resiliency, and healing.