I sat down, (well zoomed), with Stephanie Davis at the end of August. Having a PhD in leadership studies, I am always interested in how people lead, whether that be in a larger clinical setting, a teaching practice, or in the ways they run and show up in their clinical practice. Knowing Stephanie from the BBP community, and as the co-owner and director of a large teaching clinic, I was curious to hear what she had to say about this next evolution of her work, as a counsellor’s coach, and now offering two groups for therapists: Private Practice 101 and The Art and Business of Therapy, both starting this September. Here’s what I found out: (Stephanie’s words are italicized)
Tell me about the why behind you creating the workshops – what was the need you were seeing?
Let’s be honest, private practice is an idealized and popular path for those of us with training in counselling psychology and yet, none of the counsellor training programs offer any courses to support the visioning, launching or running of a private practice.
I have been in private practice as a solo practitioner, an independent contractor and now I am a group practice owner and have been extremely privileged to have found great mentorship and coaching that has helped (and continues to) support my development as a business owner and entrepreneur, but it was on me to find that support….or to even know what I was looking for.
I think that is where these workshops and the coaching work I do now, fits. As a counsellor’s coach, I see my role as helping to fill that gap for counsellors wanting to pursue the path of private practice – whether it be solo, as an associate or as a group practice owner. As a counsellor myself, I understand that the clinical and business components of private practice are not two separate hats we wear but rather, these two pieces create a tapestry that reflects who we are as counsellors, business owners and leaders within our communities. Together, these two pieces showcase our values and enable us to be authentic and congruent in both our clinical work and as the architects of a framework that sustains a growing and thriving business.
In our clinical training and ongoing supervision, there is much emphasis put on understanding ourselves, noticing the way we are showing up and how it supports or hinders the client, but that I see a lack of exploration when we are navigating the complexities of where the clinical meets the business. For example, the most common struggle that we see with our interns early in their training is knowing how to talk to clients about rebooking. Oftentimes clinicians feel worried about how it will be perceived by the client if they suggest rebooking: What if they didn’t like me? What if they don’t find what we talked about today helpful? What if I didn’t do enough? Alternately, others avoid conversations about rebooking because they feel it is important to honour the client’s autonomy, and trust they will reach out again when they are ready. Our individual motivations need to be explored.
I don’t suggest to know what is the best way fortherapists to rebook with clients, but what I do know about these two paths is that they are more about the therapist than the client, and that often the therapist is unaware of the underlying source of this anxiety, or that there is any anxiety at all. If this kind of discomfort occurred in the middle of trauma processing, therapists would more easily assume themselves to be engaged in some sort of enactment or transference dynamic with their clients, and would seek supervision to support this personal exploration, and yet when it comes to things like rebooking, cancellations, asking for payment, etc. my experience is that therapists don’t think about undertaking a similar process in the pursuit of congruence and authenticity….and good client care….
So…these workshops are about filling the gaps in supporting therapists to develop the leadership skills required to walk alongside their clients both clinically and while creating and maintaining a business framework that is value aligned and congruent. There will also be lots of tips and tricks that I’ve learned along the way.
Yes, I think there’s an unspoken discourse that being a therapist and running a business are somehow at odds…and I always think about sustainability because so many therapists ride the edges of burnout in their career. I get curious, what’s specifically unique about your approach?
I think what makes me unique is that as a counsellor and coach, I recognize the interconnectedness of the business and the clinical. Whenever I have sought out coaching to support my business development, the most challenging parts have been when (what I am sure is) sound business advice rubs up against some of the ethical or clinical complexities that come alongside doing clinical work and running a business. And the coach just didn’t get it. As a clinical supervisor and business coach, I honour and hold the clinical work with all the importance it deserves and that informs much of how I understand the business framework to be built.
Additionally, I think it helps that I don’t ascribe to a belief that there is a ‘right way’ to be a therapist in business, rather I aim to create a space for therapists to reflect with what it means to be valued, aligned and congruent, and then support them in evolving their business and clinical practice to be in alignment.
It sounds like you have a specific call that informs your coaching work.
I think at the core of what makes a good private practice clinician is leadership and there is a significant gap not only in training, but even in the role of therapist being seen that way in our larger society. We walk alongside some of the most vulnerable people in their time of need, and there is a responsibility in that to be able to maintain steadiness, authenticity and congruence (I know, I’m preaching to the choir…) alongside clear communication, integrity, and the like, regardless of whether we are in the middle of a piece of clinical work, hustling for clients or having conversations around payment, cancellations or rebooking with our clients.
To bring leadership into therapy is at the essence of what we do as clinicians, to create the space and place for people to grow and thrive. This is the quintessential quality of leadership. We seem to have no qualms about investing in clinical training, but neglect training and support in the business of therapy. The business of one’s private practice is so interwoven into the clinical, that having training in how to navigate that piece, within a larger conceptual framework that is both value aligned and oriented to a process of change, is integral.
Okay, now I want to know about these workshops! – tell me about them.
Both workshops I am offering this fall are running 2 hours bi-weekly for 6 weeks.
Private Practice 101 asks: ‘what does it mean to be a therapist in business?’ In answering that question for ourselves, the emphasis will be on exploring the values of the therapist as they pertain to their clinical work and the ways in which those help to inform the foundation of their business development. We will address many of the common challenges and struggles facing new private practitioners, and explore the patterns that may be creating obstacles to overcoming those challenges. We will explore the concept of leadership and how it lives in the counselling space as we work with our clients clinically, while maintaining a sound framework to make our practice viable, successful and sustainable. We will also build community, hold each other accountable and celebrate wins together. There will also be lots of logistical tips and tricks that have been shared with me, and that I value immensely, and that I am paying forward.
The Art and Business of Private Practice asks: ‘what comes next for me?’ for those in solo practice or those working as associates in a group practice. This question is meant to broadly address both the little changes that we can implement to help us move forward in an area we’ve been stuck or to address the larger questions that are standing in the way of us growing our practices. In answering that question, we will be auditing the values that live at the foundation of our individual practices. We will be reflecting on strengths – what has worked or is working well – and explore where folks are finding themselves stuck. We will explore how our own patterns – often invisible to us – can be limiting us and leaving us unclear about how we want to grow as therapists in business. As in Private Practice 101, we will explore the concept of leadership and how it lives in the counselling space as we work with our clients clinically, while maintaining a sound framework to make our practice viable and successful. We will also build community, hold each other accountable and celebrate wins together. There will also be lots of logistical tips and tricks that have been shared with me and that I value immensely that I will be paying forward.
Your workshops sound great. How do folks know if they need them?
My invitation is to ask yourself what values lie at the heart of why you work in private practice (since it isn’t the only way to engage with this kind of work) and how are you working in alignment with those values when it comes to making decisions that pertain to your business and livelihood, and not only your client’s clinical care?
I also think this is for folks who are struggling with having challenging conversations with clients around booking, cancellations, payment, fee structure, or even laying out a clear treatment plan. This workshop is an invitation to explore what patterns are contributing to these obstacles. Lastly, if you love the idea of private practice, are feeling confident in your clinical training, but are feeling really lost in how to set yourself up to run a business that can be authentic and congruent, these would be great workshops for you.
One last thing, tell me five things people will get from the workshops?
Greater insight into their values as a business owner/therapist and how they are working in alignment with those or not and what challenges need to be overcome in order to feel more congruent
Greater understanding of how leadership skills and the embodiment of leadership within private practice can increase confidence and create greater congruence between the business and the clinical
A greater sense of confidence in having challenging conversations with clients around the administrative or business pieces required to run a sustaining practice
A community of support alongside other private practitioners navigating similar challenges and with similar questions
Lots of tips and tricks from my years of experience in solo practice, as an associate and now as a group practice owner.
Wow, it sounds like you are opening the space for therapists to unravel their shame (or the collective shame) around creating and running a successful and sustainable clinical practice. Thanks Stephanie, I look forward to catching up and hearing how the workshops go.
If you are interested, book a discovery call with Stephanie, or learn more atwww.stephanieldavis.com
The following post is from the British Columbia Association of Clinical Counsellor’s Insights Magazine, Spring 2023, p. 34 -35.
What is Somatic Attachment Psychotherapy?
The heart of Somatic Attachment Psychotherapy (SAP) and SAP trainings is the reparation of early attachment injuries through a framework that weaves together: attachment theory and application to clinical practice, trauma research and practice application, affect and autonomic nervous system (ANS) regulation, somatic psychotherapeutic principles and practices, and relational/interpersonal psychoanalytic psychotherapy. SAP therapists are oriented to the reparation and regulation of the neurophysiological body and wounded psyche, by facilitating shifts in affect management strategies, attachment patterning, re-organization of the body and psyche, and, in supporting the maturation and development of complex right brain functioning. In the broadest sense, Somatic Attachment Psychotherapy is an embodied, relational orientation to psychotherapy that considers attachment and affect regulation as foundational for healing trauma, with the goal of integration and re-organization of the Internal Working Models (IWM) and neurophysiological regulation capacity. Additionally, the therapeutic relationship is paramount in offering dyadic regulation, completing absent or distorted affective communication cycles, and working psychodynamically with relational material.
What client concerns is it especially effective for?
This orientation leans into clinical application of multiple theories and principles, giving it wide application to diverse practice populations, with SAP students and graduates creatively applying it across diverse settings and populations, including: private practice, clinical mental health, addictions, sexualized abuse and violence work with adults and children, work with neurodiverse folks, the 2SLGBTQQIA+ community, Indigenous communities, school and university counselling centres, cancer care, and group work, to name a few.
How does it work?
This orientation responds to clients wishing to heal injuries of the psyche and bodyself that inhibit how they imagine and live their lives. With a focus on disrupting and processing that which is distorted, dysregulated, or disavowed, the SAP orientation seeks to facilitate emerging, expanding, and flexible ways of relating—to self, others, and the world. For many folks with relational trauma, their integrative capacities have been significantly impacted by their early relational experiences (insecure attachment), about 42% of the non-clinical population (Bakermans-Kranenburg, & van IJzendoorn, 2009). This inhibits clinical work, as the psyche unconsciously thwarts affective processing of the unbearable affect of trauma, both relational and incident. The SAP orientation works to build integrative capacities over time by working with the distorted and fragmented IWM of insecure attachment; facilitating increased affect and ANS regulation, and; attending to, and bringing into awareness the recapitulation of early unconscious relational patterns that continue to reinforce (mal)adaptive relational strategies in current life.
While back and forth dialogue is essential, there is a bias towards working directly with the body, and with right hemispheric (RH) processes, seeking to build congruence between the explicit (narrative) and implicit (body) systems. In this way, this work departs from traditional left hemispheric (LH) therapy by consistently returning to the bodyself and the RH, where trauma is held and needs to be processed.
How long have you been using it and what do you like best about it?
The SAP orientation to clinical practice and psychotherapist training is the culmination of my evolution as a therapist, learner, and educator over the past 19 years, and continues to evolve as I deepen my personal and clinical understandings of what it takes to sit with, and deeply witness suffering—to traverse into the abyss of trauma, and return to the living. Essentially, this work seeks to hold, witness, and help metabolize the unbearable within a collaborative, therapeutic relationship. In this process, I have had to reach beyond different psychotherapeutic disciplines, and find bigger and bigger canvases to practice this art we call psychotherapy. SAP is an orientation where heart and academic rigour meet. I have been offering the two-year Somatic Attachment Psychotherapy training program since 2016, and we are currently registering for our 9th cohort.
SAP is a relational psychotherapeutic orientation and not intervention driven, so as a clinician, I value the diversity, creativity, and depth of contact that it supports in service of reparation of early attachment injuries, as they present across the lifespan. I also rely on and appreciate the focus on embodied experience in terms of regulation and tracking my own internal responses. I find this sophisticated information invaluable to clinical practice and it is essential in terms of preventing vicarious trauma. Because this is so important, we begin the process of embodying this on day one of the SAP two-year training.
Which other modalities does it pair well with?
With such diversity and breadth in the theoretical underpinnings (attachment, relational/interpersonal psychoanalytic psychotherapy, affect and ANS regulation, and body-centred/somatic practice with RH processing), SAP pairs well with numerous modalities, and can often provide a framework to understand what is happening in the body and ANS, the attachment system, and the therapeutic dyad, that can deepen the clinician’s understanding and increase the traction and effectiveness of clinical work. I see many creative pairings where students apply SAP to: art and play therapy, family systems work, couple therapy, narrative therapy, EMDR, and analytic or psychodynamic oriented work.
If applicable, are there any clients/client concerns it should NOT be used with?
I think what’s more apt is that the way in which the work looks will differ with different populations, presentations, and clinicians. For example, understanding what is happening in the ANS, (client and therapist), and how this impacts what is happening clinically is imperative no matter who we are sitting with. Having said this, the training is oriented to working with clients with relational and incident trauma. More severe presentations of mental health disorders are beyond the scope of the training, and additional specialization would be necessary for people working with these populations.
Where can I learn more?
Upcoming trainings and workshops can be found at www.bringingthebody.ca, where you’ll also find links to published articles about Somatic Attachment Psychotherapy, blogs, and a graduate referral list.
References
Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2009). The first 10,000 Adult Attachment Interviews: Distributions of adult attachment representations in clinical and non-clinical groups. Attachment & human development, 11(3), 223-263.
Incident trauma enters our lives unanticipated and uninvited. It ruptures the fabric of life and can be devastating—whether it be motor vehicle collisions, medical diagnosis, assaults of any kind, natural disasters, accidents, illnesses, loss, and the list goes on. As therapists, we need to be cognizant not only of the intense disruption and dysregulation to the autonomic nervous system (ANS), but we need to be aware of the disruption to identity that often comes with the experience. The loss of self, the loss of who I was, who I am, and who I can become, can be called into question, depending on the type and severity of the trauma, the disruption, and the injuries—psychological, neurophysiological, and physical.
One of the things I talk about as a trauma therapist and educator, is that the theory and process of metabolizing incident based traumatic material is relatively straight forward, particularly when there is a secure base, as there is with secure attachment—where there is a foundational integrity of the integrative functioning within the self. Often healing or resolution gets stymied when working with a person who has an underlying insecure attachment, where there is a deficiency in the integration capacity in the bodyself. This is when we as therapists, are called not only to travel to the abyss of trauma itself, but to negotiate that journey with a psyche and ANS that have foundational injuries that unconsciously thwart the integration of material. Kalsched (1998) aptly captures this dynamic: “for the traumatized psyche, integration is the worst imaginable thing, apparently equivalent in the ‘mind’ of the defending Self to some early horror—never to be repeated. It is as though integration threatens a re-experience of the ‘unthinkable’ affect. Therefore, connections among the components of experience are attacked in true ‘auto-immune’ fashion” (p. 89). These defenses are employed to maintain some stability in the system and to protect the psyche from re-experiencing the unbearable anguish of the affective experience of the trauma—the terror, pain, and unknown. For the insecurely attached system or psyche, the processing of traumatic material is threatening—too threatening for the systems to allow it to emerge, to surface, and involuntarily, unconscious defense structures emerge to shut down the process.
As clinicians, we also need to be cognizant of ramifications of what happens after a traumatic event, and the myriad of ways in which people’s early relational dynamics may be replicated as they navigate their post trauma reality. For some folks who have to interact with insurance companies (disability or otherwise), the medical and legal systems, employers, and other institutions, they may experience the recapitulation of their relational dynamics of early life. This can be particularly potent when interfacing with overburdened or profit driven systems, where they are left to languish unattended and in the unknown, a familiar abyss for some.
The Canadian healthcare system is a prime example, where people often wait for months to over a year for diagnostic imaging, access to specialists, and for adequate pain intervention and management, all of which can feel like there isn’t anyone to help them, evoking experiences that: no one cares, they don’t matter, no one sees them, etc., which may be reminiscent of early experiences wired into their internal working model. We can also see replication of early life experiences activating feelings that: there’s not enough for me, I have to manage this on my own, there is no relief, I don’t know what to do to make it better, to feel okay, to be safe—all of which can incite fear, anger, and/or helplessness for people, and complicate healing.
When people land in our clinical practice, we as therapists must be aware of the post trauma context in which people are living. For some clients, they may feel unmoored and unsafe, due to the recapitulation of early relational injurious experience, which destabilize them and needs to be attended to in the treatment process. In attending to our clients with this larger lens, and being tuned to the underlying relational security, or lack thereof (as with insecure attachment), therapists are better able to understand the complexity of processing traumatic incidents when there is underlying relational trauma.
References:
Kalsched, D. E. (1998). Archetypal affect, anxiety, and defence in patents who have suffered early trauma. Post-Jungians Today, 84 – 104.
The Body is Foundational for Somatic Psychotherapy
Psychotherapists are often curious about, how do I bring the body into my clinical practice? To be clear, we are always working with the body—whether we are adept at listening, deciphering, and utilizing the information is another story. As a therapist educator, the question then becomes, how do I assist clinicians to bring the body–theirs and clients—into practice. Conceptually, I speak about this in three key components: right brain to right brain, body to body therapeutic practice; embodied practice: and working with the modes of the right hemisphere.
Right Brain to Right Brain, Body to Body Therapeutic Practice
Bodies are always communicating under the, or embedded within, verbal dialogue. As clinicians, our capacity to regulate our autonomic nervous system (ANS) and offer dyadic regulation allows opportunities for dyadic regulation that over time increase the client’s capacity to regulate their own system—such regulation is at the core of both relational and incident trauma repair.
Therapists also need to be cognisant of the non-verbal communication that happens between bodies—the tone of voice, facial expression, and the way the body moves, or doesn’t, all transmit information beneath the dialogue to the other, as does each person’s current internal state. This transmission of information, either increases or decreases a client’s sense of safety (often unconscious), and its accurate interpretation or neuroception (Porges, 2011) is shaped by number of factors, including: their history; what is happening in the moment in the therapeutic dyad; the therapist’s ability to regulate; and the congruency of the therapist’s words and internal experience. This also can be true in reverse, where the attuned therapist registers discrepancies in congruence of the narration and physiology of the client—this can open a doorway for process. The therapist is also susceptible to their own history colouring their perception or neuroception of the therapeutic work, particularly when they are dysregulated. Given this, the capacity for the therapist to regulate their own ANS is integral to all somatic or body-centred practice, and I would propose, to good therapy in general.
Embodied Psychotherapy
Embodied psychotherapy for me, speaks to the valuing and use of the therapist’s body, and the client’s body, in clinical process and practice. By this, I mean a few different things that can be summed up as the therapist using their body to feel into and resonate with the client’s body as they bring content, both psychological and physiological, into the work. In using one’s body to feel into, regulate, and resonate, therapists are better able to: catch nuanced, or discrepant material that needs attending; track shifts in their ANS state and the client’s state in the moment; feel into the dissociated material that is out of the client’s awareness, and; track dyadic connection and disconnection. In using the body as a tuning fork, therapists are able attune, sophisticate, and nuance their clinical awareness, enhancing relational contact and collaboration in the clinical process, both moment to moment, and over time.
With embodied practice, therapists also lean into the conceptual framework of the window of tolerance (Siegal, 1999), utilizing their embodied awareness to track and then up or down regulate affect and content to help guide the processing of material. Further, use of Porges’ polyvagal theory (2011), in combination with the use of sensations and felt sense, is used to decipher what is happening in the ANS. In combination with this and other bodily based information, the therapist discerns in the moment whether to stay the course, or up or down regulate the system—this can happen in several different ways, ranging from increasing relational contact to making interventions to disrupt the ANS state. What I am meaning here, is that with embodied practice therapists tracks whether there is enough regulation and vitality in the client’s ANS state, or if more ventral vagal is needed to regulate and support the metabolizing of material—so, down regulating in the case of too much sympathetic arousal in the ANS, or upregulating when the ANS has too much dorsal vagal state dominance to metabolize material.
Right Hemisphere Processing in Psychotherapy
We understand that trauma is held in the body and right brain, and that left hemispheric work is refractory for trauma resolution. With this understanding, in addition to right brain to right brain, body to body process, and embodied practice, somatic psychotherapy utilizes processing through the different modes of the right hemisphere—sensations, sensory motor or gestures, emotion, images and the imaginal, including metaphors and analogies, and the symbolic or archetypal realms. In doing so, the psyche or bodyself brings into awareness unmetabolized and unintegrated material. In working in the right (rather than left brain processing) and processing through right hemispheric modes, traumatic material can begin the process of metabolizing through linking and differentiating elements of the experience, which supports regulation, organization and ultimately integration, all in service of change.
Wrapping Up
Admittedly, this blog just scratched the surface of how to bring the body into clinical practice. My hope is to alight more curiosity by opening your attention to these different but related elements of how the body can be utilized in somatic psychotherapy—right brain to right brain, body to body therapeutic practice; embodied practice: and working with the modes of the right hemisphere. As a therapist educator, I witness profound changes in therapist’s clinical practice, and their capacity and acumen, as they embrace and embody a somatic orientation in their work.
References
Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, self-regulation. New York, NY: Norton.
Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. Guilford Press.
Chronic shame is deeply woven into the stories and neurophysiology of many of clients seeking therapy. Because chronic shame is a relational injury, with its roots in early life, it is woven into the fabric of the self and largely nonverbal in origin, impairing healthy relational capacity, disrupting regulation, and most significantly, distorting one’s sense of self. This early wiring of the psyche and body becomes the shaky ground that further shaming experiences across the lifespan are built upon.
In clinical practice, chronic shame shapes the therapeutic work and relationship, this can be both confusing for client and therapist, and can be a forceful inhibitor of the therapeutic process. In my teaching and clinical practice, an area of focus when working with clients who struggle with chronic shame, is meeting the underlying emotion that is present, but often inaccessible below the content—to listen below the words.
In therapy, clients often offer appraisals of themselves and their inherent lack of self worth or value which are truly heartbreaking and categorically untrue. In these moments, therapists get to glimpse the tormented, distorted inner world of the client. In response to this anguish, therapists can feel compelled to offer kind and (often) accurate assurances to the contrary, attempting to talk them out of their bleak view of themselves, to provide them (and the therapist) some respite from the suffering which has now enveloped the therapeutic space. This will have little effect.
Despite the best clinical intentions, meeting chronic shame head on through cognitive means is counter productive, and Schore tells us, refractory (2015). It often initiates an attack or collapse within the client—a reflexive defense of their distorted position, which to the client feels irrefutable on all levels, cognitively, emotionally, and neurophysiologically, due to the well worn and catastrophic shame cascade. Additionally, there is often a myriad of examples from their history that verify to themselves their distorted assessment. Engaging too cognitively with chronic shame activation puts the clinician into conflict with the client’s understanding of themselves, the world, and their place in it; with our words, often not heard as accurate, or exploratory, or true, but misheard and misinterpreted as threatening, pitying, mocking, or just plain wrong. The other side of this mishearing and misinterpretation, is for the client to hear us as confirming their worst beliefs, adding yet another layer of ‘proof’ to their bleak belief of self. This creates a delicate and difficult therapeutic dance, that can easily activate the therapist’s own feelings of inadequacy, inefficacy, and shame. So, given this dynamic, what to do?
In working with clients with chronic shame, we want to keep our ears, and even more importantly, our hearts, tuned to listen for the painful emotional truths that exist below the thinking, stories, beliefs, and appraisals that they offer up in therapy. Our attention is tuned to listen for the emotion that is below the client’s words, what may be largely out of their awareness, what is too painful to share or tolerate. Therapists want to listen for the loss, the pain, the fear, the sadness, and the relational cruelty that the client endured. It is these events and experiences which created the necessity for chronic shame to exist for them as both a source of protection, and (unwittingly), the creator of immense pain. Therapists want to listen for the excruciating double bind that exists for these clients—wanting to connect with people, and the fear and threat of connecting—as people have been the source of their pain. This fear extends to, and is often exacerbated within the therapeutic relationship.
When we notice these underlying truths of loss, longing, sadness, grief, etc., we can gently, and with absolute congruence, reflect back what we are seeing and tracking emotionally, how we imagine it was for them at the time of the experience or in the relationship, or how their words are impacting us in the moment, to name a few. Our therapeutic intent is to respond as a caring, engaged, interested person, something which has often been so lacking in the lives, particularly the early lives, of our clients with chronic shame. We want to offer a glimpse of a new relational reality where their words and experiences have meaning and touch others.
I have found that over time, through attuned attention to the underlying emotions existing below the chronic shame, clients become better able to take in (if only for a moment), the reality and truth of what is being reflected back to them, and get a clearer view into their emotional world which has been disavowed, dissociated, and distorted. As this expanding view of themselves becomes internalized, the world, their place in it, and the possibilities for living (hope, creativity, dreaming, excitement, etc.) emerge, inviting growth and greater freedom in all areas of life.
References
Schore, A. (December 2015). Allan Schore Seattle Study Group.
Attachment theory and research seems to be everywhere these days and I routinely hear from clinicians, how do I apply attachment theory to my clinical practice? Having had the immense privilege to train with Dr. Mary Main and Dr. Erik Hesse in the Adult Attachment Interview, and with Dr. Allan Schore, who writes on modern attachment theory and regulation theory, I have spent many years integrating and educating therapists on the application of these teachings to clinical practice. So, in a nutshell (or a blog post), here are some salient ways that I apply attachment theory to clinical practice, specifically working with insecure organized attachment (dismissive and preoccupied) from a Somatic Attachment Psychotherapy orientation.
The Therapeutic Relationship
We know that our relational wiring, established through the early caregiving experiences, fires at pre or unconscious levels of awareness, so, using and making explicit the relational dynamics emerging in the therapeutic relationship can be a potent way to bring relational patterns into the here and now. For clients to feel and identify ways in which their underlying beliefs operate out of awareness, such as: I have to disavow my feelings to protect our relationship; I have to take care of you so you can take care of me; I have to accommodate you to preserve our relationship, I’m too much, I’m not enough, etc., can illuminate potent understanding. In bringing awareness of these relational patterns from the implicit to the explicit, we can process how these patterns of relating emerged in early life, and how they continue to limit what is possible today. With this emergent awareness, folks can make better sense of their life and relational patterns, work toward deeper understanding and compassion for self, and begin disrupting their habituated relational ways as they evolve into more flexible patterns of relating.
Internal Working Models
The internal working models that emerge through early caregiving experiences wires how one understands who they are, how relationships work, and how the world works. We can listen for attachment material that pertains to the IWM such as:
the distorted self – ex) I am bad, I am unloveable, I am needy – as well as, tracking and attending the protective self-care defences that undermine or persecute the self
distorted relational understandings – ex) I have to disavow my needs/feelings/wants to maintain our relationship
distorted understandings of the world – ex) bad things happen when I’m happy, people aren’t safe
As these distortions come to light, we can work to disrupt the fixity or certainty of these beliefs that run at various levels of consciousness, bringing fuller awareness, which in turn, allows for a renegotiation of experience and relating over time.
Affect Regulation
We know that dyadic regulation is necessary to establish self regulation capacity where people can have flexibility in regulating their autonomic nervous system – ANS. One of the hallmarks of insecure attachment is the lack of flexibility in their regulation capacity, meaning that they can have difficulty leaning into co-regulation (think dismissive attachment) or alternatively, lack capacity to regulate their system on their own (think preoccupied attachment). Through the therapeutic relationship, we can offer dyadic regulation to, over time, shift the wiring of the ANS so people are able to increase not only their capacity to regulate, but increase the flexibility in the ways they respond under relational distress. In working to increase one’s regulation capacity, we work with finding safe pathways into the body or felt sense, shifting ANS states, attending and processing relationally, and leaning into organised or coherent self states.
Thinking and Feeling
We can listen for biases toward thinking or not thinking, feeling or not feeling, that will give us some information towards what modes of processing or, said another way, what defences have been utilised to manage early, less than optimal, relational care. In broad generalizations, we can think of preoccupied states of mind as defending against thinking and often having difficulty containing and regulating their intense affect. Alternatively, we can think of dismissive states of mind defending against affect and finding haven the left hemisphere, the intellect.
Given these broad strokes, when I sit with folks with these presentations, I work towards helping them build pathways into the less developed modes of process. In thinking about folks with a more preoccupied state, we work to develop and enhance their witness self so they are able to experience more continuity of self, and story, rather than being hijacked by their intense affect. With more capacity to regulate, and be in contact with the self, they are better able to stay in the here and now, and work to metabolize experience, coming to more truth or clarity about who they are and what they need or want.
In sitting with folks with a more dismissive bias, our work, in part, is about creating enough safety so they are able to access the emotion that is present and defended against. In bringing regulation and relational connection, their stories become less rigid and more emotionally nuanced, opening them to increased understanding of self and context, and more nuanced experience of relating.
Wrapping Up
In writing about the translation of attachment theory to clinical practice, I think one can portray a simplicity to a very complex and nuanced way of seeing and understanding lived experience, and working toward reparation of early relational injuries. The ongoing tracking and attending to attachment material, to what is happening in the relationship, how we as therapist are engaging, and how our own attachment biases are alive, is demanding and beautiful work that continues to challenge our growth and capacity, and offer rich clinical practice.
