David Wallin on Attachment and Psychotherapy

David J. Wallin: Gotcha.

DW: When I first read the quote and was drawn to it, I thought what it meant was “only connect to other people,” but actually, I think what Forster had in mind was to connect the various parts of oneself. I liked the ambiguous, double meaning of that: how we connect or don't connect to other people, but also the ways in which we connect or don't connect to various aspects of our own personalities.

DW: My own development as a therapist traced a pretty common pathway from a classical psychoanalytic approach, then to ego psychology and object relations theory, self psychology and the intersubjective and relational perspective. I felt I'd found a home when I'd found relationality and the intersubjective perspective, because it seemed to speak to the essentially relational quality of the practice of psychotherapy.

I'd read John Bowlby as an undergraduate, and I'd probably dipped into Bowlby at various points along the way, but I was not terribly familiar with attachment theory. Then I began subletting hours in my office to Nancy Kaplan, who happened to be one of the three authors of the Adult Attachment Interview. I went out to lunch with her one day and said to her, “I wonder, is there a particular book or an article that you would recommend to me to begin to wrap my mind around attachment theory? Because I'm very interested in it.”

And Nancy said, “Well, I can't really think of a particular book, but let me pull some stuff together for you.” The next day I came to my office and there was a grocery bag full of books, a stack a foot and a half high of chapters and articles.

So I started reading, and very quickly I realized that intersubjectivity theory and attachment theory were a conceptual marriage made in heaven. Attachment filled in the largely missing developmental and diagnostic dimension of intersubjectivity theory, and intersubjectivity filled in the largely missing clinical dimension of attachment theory. So wedding the two provided a framework for understanding what goes on in development, psychopathology, and psychotherapy.

David J. Wallin: Attachment theory was and is primarily a theory of development. Secondarily, it's a theory about how development goes awry and results in what we might call psychopathology. It's also generated a lot of research. But it's not primarily a clinical theory.

Bowlby had written a book called A Secure Base, where he talks about attachment theory in relation to psychotherapy, but he doesn't go that far with it. Attachment theory is a relational theory about how we develop in the context of relationships. Intersubjectivity theory and the relational perspective are theories about how people change in psychotherapy. If you transpose a lot of what the relational, intersubjective theorists have to say about how the therapy process works to the developmental context provided by attachment theory, you've got an extraordinarily rich framework for guiding your interventions in psychotherapy. At the same time, that way of putting it, I think, makes it sound like one's work as a therapist is probably more guided by theory than in fact it is.

DW: Precisely. I think that's part of the important meaningfulness of both theories. Indeed, Bowlby was very discontent with the analytic explanations of his day, which seemed to explain development and psychopathology exclusively on the basis of what went on inside people, and their fantasies about what went on between them and other people.

DW: Exactly. The focus was on the child's fantasies and how those shaped the course of development, and the focus in psychotherapy was on the patient's fantasies and how those shaped the unfolding transference-countertransference situation. Bowlby realized that that was a ridiculously incomplete way of thinking about what actually happens in relationships between parents and kids, or patients and therapists. Similarly, intersubjectivity theory is a very lengthy retort to Freud's notion about the necessity that the therapist function as a blank screen, surgeon-like, staying above the fray, which I think is impossible.

DW: I think the short version is that it was the research that I found interesting. It wasn't so much Bowlby's books as the work of people like Mary Main, Peter Fonagy, Mary Ainsworth—others who were testing Bowlby's ideas and extending them, in ways that had tremendous clinical usefulness.

Mary Ainsworth initially identified two ways in which development goes awry in childhood, what she called avoidant attachment and ambivalent attachment. Mary Main discovered a third way in which development goes awry: disorganized attachment. And those scientifically researched variations on the developmental theme I found very compelling, and certainly more compelling than conventional diagnosis, which had once been very interesting to me.

DW: I'm talking about hysterics, obsessives, borderlines, schizoids, paranoids, and so forth.

DW: The attachment categories gave me a way to both understand the states of mind in which my patients seemed to be lodged at particular times, or the states of mind in which I seemed to be lodged at particular times—and also to imagine something about the childhood relationships that might have given rise to those particular states of mind.

For example, I began to think about the patients in my practice who might be described as dismissing. The dismissing state of mind is the adult corollary to the avoidant attachment classification in infancy. I found myself thinking about these patients who seemed to be remote from themselves and remote from other people as adults, who as children had needed to remain at something of a distance from their parents, but also from aspects of their own internal experience that might have driven them to try to get closer to their parents.

I was able to look at my patients' experiences through a theoretical lens that was orienting and helpful—and, ultimately, in my thinking through of this whole matter, allowed me to come up with some theoretical guidelines for how one might helpfully intervene with a patient who's in a particular state of mind with respect to attachment. I also had to think about my own states of mind with respect to attachment, in ways that seemed to have some implications for how I might attempt to conduct myself.

DW: That's right. For example, somebody who is fairly dismissive, seems very cool, who begins the session, by saying, “How are you doing?” “I'm okay. And yourself?” “Fine. Doing fine” despite things going poorly in their life. With somebody who's really at a distance from his or her own internal experience, emotions, bodily sensations, and so on, I tend to assume that I'm going to have to learn about what's going on in the patient in significant measure on the basis of what I become aware of going on inside myself.

DW: I think that's true. I think with a patient in a dismissing state of mind—I notice I'm making that same gesture—I think one can feel pushed away. This might be somebody for whom connecting in psychotherapy to what's going on inside is going to be very important to the patient, but the patient is often not going to be able to do that on his own. Everything inside the patient and in the patient's history works against making those connections between their conscious self and their internal experience.

I also tend to assume that what we can't allow into our awareness of our experience—which also means what we can't talk about, what we can't think about—we tend to evoke in other people. So I'm inclined to believe that by paying attention to what's going on inside myself, I may get some clues as to what's going on that is most salient inside them.

I might be feeling pushed away because the patient's pushing me away. But this is, I guess, that old standby, projective identification. Often what I find myself experiencing is in some way a reflection of what the patient is really experiencing, in Freudian terms, in a kind of a preconscious way. In other words, it's kind of on the tip of the patient's tongue, emotionally speaking, but he or she is out of touch with it.

DW: I think that when we lack words for our experience, our experience tends to be much more gripping, much more overwhelming. I think having words is a way to communicate about our experience, so that putting hitherto unverbalized experience into words allows us to feel less alone with it. And feeling less alone helps us to feel less overwhelmed. Putting experience into words is a part of how we integrate experience.

DW: Number one, it creates an emotionally live exchange, which is a big part of what I think can be missing in the therapy with patients in this dismissing state of mind. Therapy can be a conversation of talking heads—low on life, low on emotion. So when the therapist leads with his or her own emotional experience, that can open things up for the patient. I think there's a kind of modeling there: it may be safer for the patient to think and feel, or safer to feel certain things, than he or she may have thought possible. And if the therapist models that, it opens up possibilities for the patient.

There's this great quote from Bowlby, where he quotes Freud saying that, for the patient who is discovering what he previously believed forgotten, there's almost always the same sensation, or the same words might be spoken, which are I've always known that, but I never thought it.

DW: Yes. Christopher Bollas, with his book, The Shadow of the Object: Psychoanalysis of the Unthought Unknown, may well have read that same passage in Freud. In any case, the idea there is that patients often know more than they can put into words about their internal experience. So when the therapist articulates some aspect of what's going on in experience, the patient often recognizes it.

DW: I remember talking to this one patient—this was a guy who had me feeling, first of all, like he was about to walk out the door any minute. He was only in therapy because his wife insisted that he get into therapy.

Virtually from the beginning of therapy, I had had this sensation that I was only able to describe to myself by the third session. The sensation was that I was on the witness stand dealing with an exceptionally brilliant and aggressive prosecutor, and my language had, consequently, to be bullet-proof. At a certain point, I felt like the patient was probably going to quit anyway, so I might as well say what was on my mind. So I told the patient that this was my experience. And he said something like, “That's incredible. You're describing my experience.” But he had never been able to put anything remotely like that to me previously, so that was the point at which something clicked in the therapy, and the patient wound up sticking around for a couple of productive years.

DW: Absolutely. I think the therapist's subjective experience when working with patients is almost always a valuable resource.

DW: Yes, whether it's spot-on or not.

DW: Exactly. And sometimes what I have to say really rings a bell, strikes a responsive chord, and other times, although more rarely, it doesn't seem to fit. It's my sense that there is almost always a meaningful, rather than an accidental, relationship between what the therapist is experiencing in the session and what the patient is experiencing.

DW: Yeah, that's a good question. That's for sure. And I think that, as time has gone on, I've been personally less and less gripped by that bias, but there are certainly times when I'm still enthralled by it and may hesitate to disclose something of my own experience.

For what it's worth, I have found that when I have disclosed my experience, far, far more often than not, it seems to have a fruitful outcome. In other words, the emotional involvement of the patient and me seems to deepen, or we get into some material around which some meaning seems to emerge that hadn't previously been apparent to either of us.

I must say, though, that there have been a handful of occasions on which it's kind of blown up in my face, but generally that's happened when the disclosure has come out without the slightest reflection and bursts forth, perhaps angrily, from my side. And there have been a couple of occasions when that's turned out to be extremely problematic.

DW: But of course that's true of any intervention.

DW: Or interpretation, or a joke, or advice, anything.

DW: “You're not one of those therapists who never says anything, are you?” (laughter)

DW: I've heard that question before.

DW: The primary criterion for me is, “Do I think this is going to be in the patient's interest?” How I gauge whether or not it's in the patient's interest is probably difficult to say.

Certainly there are some disclosures where you blurt something out. And sometimes that's okay and then comes spontaneous interaction; it's probably a healthy feature of many successful therapies. But I think if I'm considering in my own mind, “Is it going to be useful to say something about my experience here with a patient?” generally the criterion is, “Can the patient make use of this? Do I expect that the patient will be able to make use of my experience? How is the patient going to be able to make use of this?”

DW: I think there's a real skill involved in presenting one's experience to the patient in a form that's usable. I think there are the nuances of language that come pretty automatically to me, which I think wind up having the patient feeling that what I'm contributing, what I'm disclosing, is not a threat. It's not a criticism. It's not a demand. It's something for the two of us to see together if we can make use of or not. But I think those same nuances in language are probably vitally important when you're making an interpretation or asking a question, or whatever. There's ways to talk that are more or less easy to listen to.

DW: When you write a book, it can be a wonderful magnet for other people's responses. I got an email out of the blue from Louis Breger, whose book, From Instinct to Identity, I had read when I was a graduate student at The Wright Institute in the ‘70s. He liked my book very much, but he raised the question,

“To what extent do we make the mistake of assuming that there's no difference between the adult patient and the baby?”

My response was that if we think about therapy as kind of a new attachment relationship, it's a new attachment relationship that's between two adults, but also a relationship between the therapist as parent and the patient as baby. Or maybe, in some ways, it's also a relationship between the therapist as baby and the patient as a baby—in other words, those baby parts of our selves. You know, we don't leave those behind entirely.

DW: And the preverbal experience that remains inside us undigested. We bring those yearnings, those fears, to adult relationships. I think it's meaningful to think of that as, in a sense, the baby part of us. When that very young part of us can come alive in the relationship with a therapist, there's an opportunity for that part of us to change and to develop.

The other thing that I have found useful is to think about the research on the features of the most developmentally facilitative parent/child relationships, and use that research as a springboard to some ideas about what's most developmentally facilitative to bring to the relationship with the adult patient. There are lots of other writers—Holmes, Allan Schore, Winnicott—who've pointed to the symmetry between what we provide as good parents and as good therapists.

DW: Yes, of course. In my book I lay out four ingredients of growth-promoting relationships in childhood from which one can draw lessons for psychotherapy. One of them is the fact that the relationships between parents and kids that seem to generate the healthiest, the most flexible, the most secure, the most resilient offspring, tend to be relationships that are maximally inclusive. In other words, they make as much room as possible for the depth and breadth of the kid's feelings, desires, views, behavior. The kid is allowed to experience a whole lot of himself in the context of a relationship with a parent who is curious about that kid's experience and is making room for that kid's experience.

I think the same thing is true of psychotherapy. You can look at psychotherapy as a relationship in which the therapist, as an attachment figure, is attempting to make room for experiences the patient's original attachment figures couldn't make room for. So to that end, I'm interested in getting to know as much as I can about what the patient is feeling, hoping for, afraid of; what the patient wants from me, what the patient's sense of our relationship is at any given moment, what's going on inside the patient's body. I just want to make as much room for that as possible, because I think it's conducive to the integration of previously dissociated experience.

DW: Mary Main as well as Bowlby and a host of psychoanalysts makes the clinically useful point that we can think of the internal world as a registering or duplicating of what has occurred in our first relationships. But Main goes on to add that there's another way to think about the internal world, which is as a registering of rules for processing information.

In our first relationships, we learn what's ruled in and what's ruled out: what we can safely feel, speak, and want. I think of dissociated experience as experience that has been ruled out on the basis of what's occurred our early relationships. It is also a consequence of experience that is traumatic, whether it occurs in the context of early attachment relationships or later attachment relationships or, for that matter, outside the context of attachment relationships.

A lot of us are most profoundly affected, although often in ways that lie outside our awareness, by dissociated experiences that we've never been able to fully know, experiences that we've never been able to fully think about or feel, or be articulate about. Dissociated experience often really has a grip on us. It determines a lot of what we do and don't do, say and don't say, feel and don't feel, think and don't think. So as a therapist, I always have my eye out for what the patient doesn't seem free to think, feel, want, know and so forth.

In therapy, dissociated experience is often an experience the patient can't put into words, or an experience that can't even be put into thoughts or feelings. My attention often is on what is being evoked in me, because I think what people can't own and articulate, they often evoke in others. I've also got my attention on what's being enacted between me and the patient, since that's another way in which dissociated experience gets expressed.

Finally, I've got my attention on what's going on in my own body and what's going on in the patient's body, because I think often what can't be consciously known, the body knows. In some way, it becomes part of the person's somatic experience: the way he carries himself, the sensations in his body.

DW: I refer to it as somatic countertransference—what's going on in the therapist's body. I think these categories—what's evoked, what's enacted, what's embodied—tend to overlap. Sometimes what's evoked in the therapist, what the therapist experiences is a bodily sensation.

DW: Yes. I remember a number of years ago, I went to a presentation by Elizabeth Mayer who died a few years ago. She was making the point that different therapists have different resources, as you say. Some are really good at paying attention to what's going on inside the bodies in the room, and some are really good at paying attention to dynamics of transference and countertransference, and others are really, really good at working with dreams. And whatever your resources are, that's what you bring to bear on the encounter.

DW: That's sort of a hard question to answer because I don't know how other therapists work.

DW: So, in a way, all I can say is how I work.

DW: Right. I think there's probably a pretty close relationship between what an attachment-oriented therapist, on the one hand, and a relational, or intersubjectively oriented, therapist, on the other hand, might do. The primary similarity is that there's a lot of attention to what's going on in the here-and-now relationship, what's going on in the patient right here, right now, and what's going on in the therapist right here, right now.

When I'm working at my best, I'm very inclusive and integrated. There's a focus on my own internal experience. There's a focus on the patient's internal experience. There's a focus on evocations, enactments, embodiments. And then there's also a focus on this whole matter of my relationship to my own experience as I'm sitting with a patient and the patient's relationship to his or her own experience as we're sitting together. The whole question of mentalizing and mindfulness is one that's very often on my mind as I'm sitting with and working with a patient.

DW: Of course. I have a couple thoughts about that question. One is, as a therapist, I'm sure I have a lot in common here with psychoanalysts like Owen Renik (see Interview with Owen Renik) or Michael Bader, who write about the importance of symptom relief in therapy.

Very often, I'll find myself saying to the individuals or couples with whom I'm working that I tend to work at two related levels. One is a practical level: what's troubling you? What's getting in the way? What's bothering you? What can we do about that together?

And then there's another level which is more psychological, having to do with the relationship between what you're experiencing that's difficult and what you've experienced growing up, the ways you've learned to think and feel, and what you've come to believe about yourself and other people. I think if I'm leaving one or the other out, I'm not doing you any favors. So I'm going to be trying to focus on both of those goals.

DW: Absolutely. I think of these as two intertwining braids of the same rope.

I always feel like I have to start where the patient is, so I'm trying to get a sense, sort of intuitively throughout any given session, what's most emotionally salient for the patient? What's most interesting or troubling? Or if the patient seems far away from any experience, as if nothing is interesting or nothing is troubling, that gets my attention. But I think the focus on starting where the patient is at means that you're focusing largely on what's bothering people.

DW: I think there are probably a bunch of ways in which the practical level of things is ameliorated through a focus on what's going on in the therapeutic relationship. For one thing, we're talking about somebody's relationship to himself or somebody's relationship to other people, generally, that's what bugs people. That's what troubles people.

It's my relationship with myself: I'm feeling depressed, I'm always getting anxious. Or it's my relationship with other people: I'm always feeling insecure with other people, or I just feel really distrustful of other people, or I'm angry at other people, or I feel let down by other people, or other people seem more important and smarter than I am, or whatever it might be. It seems like people are bugged by aspects of their relationships with themselves or relationships with other people.

If I, as a therapist, start to pay attention to what's going on in my relationship with a patient, it provides a kind of here-and-now experience of aspects of the patient's relationship to other people, or the patient's relationship to himself, that are troubled.

DW: I am thinking of man who has a hard time feeling close to his wife and I notice is somewhat remote from me and remote from his own feelings. If I can find a way to talk to the patient about the fact that—for example, “God, we're talking about this very troubling stuff and you seem utterly unaffected. I asked you what you're feeling about it and you say ‘I'm thinking' or ‘I'm reflecting,' but you're not feeling it. I just have to wonder what's going on there; whether you don't feel safe to have your feelings when you're with me or whether you are having a hard time connecting with what you're feeling generally.”

And then later I might say something like, “If you're not feeling a whole lot about some stuff I've been saying that I would imagine would evoke a whole lot, it leaves me feeling sort of disconnected from you.”

DW: Ideally, I think the patient gets really interested: “Wow. God, I seem to be emotionally cut off from experiences that, at least according to you, ought to be really getting to me. I wonder what that's all about?”

DW: As time goes on, often bridges are made between what goes on in the therapy relationship and what goes on in other important relationships the patient has; some of those bridges are made to the past. As the patient talks about his or her experience, the therapist has ways of being with that experience, tolerating that experience, that allows the patient's experience to deepen.

DW: That's a part of it, providing a secure base. I think that means generating a relationship in which the patient feels both safe enough, challenged enough, engaged enough, understood enough, accepted enough to venture where he or she has previously felt it was too dangerous to go.

DW: As he connected with his traumatic experience.

DW: Right. I think patients have to sort of figure out, on the basis of their experience with us, whether, in fact, it is safe. Do our responses allow the patient to feel understood, accepted, or not? There is a kind of common experience with patients who have been traumatized, that it's extraordinarily difficult for them to feel safe, and I think they often manage to find unsafety in situations that we might imagine are safe. For example, they might feel that we're seducing them into a relationship with us, which they expect, on the basis of their own experience, to actually and inevitablybe a dangerous experience, a dangerous relationship.

DW: Based on my experience with a lot of different patients, confronting trauma almost invariably raises questions about the safety of the relationship with the therapist. Often these are two intertwining processes: so when you're dealing with the question of safety or danger in the relationship with the therapist, that regularly reels in issues of past trauma.

I think there's a common model, which has some meaningfulness, that we create a relationship of some safety, which provides a container within which, at some point, the patient will feel appropriately secure enough to confront the traumatic experience of the past. But I think that that model makes a whole lot more sense if you think of this not as two-stage process but rather as two facets of one process that you're going through over and over and over and over again.

In other words, if you're paying attention, you are repeatedly noticing the patient's concern with issues of safety and danger in a relationship with you on the one hand, and you're repeatedly either hearing echoes of or explicit references to the patient's traumatic history on the other hand, and you're going to be touching on one and then the other, for a good long time.

DW: When I first contemplated writing this book, mindfulness had no place in my thinking whatsoever. And it was only very accidentally—or maybe there's some synchronicity at work here, or grace, or God knows what—that i stumbled upon the whole matter of mindfulness. I just happened to be thinking one day about some of the ideas that I was writing about at the time. I was thinking about some of Fonagy's ideas…

I remember I was sitting out on my deck and I was feeling very relaxed when I had this fanciful image of three concentric circles. The outermost circle represented external reality. Within that, there was a second circle representing the representational world of mental models, and so on. And then within those two circles was a third, which stood for what Fonagy calls the reflective self, which is that part of the personality which is capable of reflecting on the relationship between the representational world and external reality.

And as I was thinking about these three circles, what seemed like the inevitable questions came to mind: Who or what is it that is doing the reflecting on the relationship between the representational world and external reality? What is the reflective self? Who or what is doing that reflecting? What's the reflective self made of?

And as I asked myself these questions, I got an answer, not in the form of a conceptual understanding but an experience. I had this sort of dizzying sense of an imploding self. It's very hard to describe, but it was as if my ordinary sense of self was collapsing down to a single point, which represented nothing but impersonal awareness. And so it seemed like the answer to the question, “Who's doing the reflecting?” was, no one, or no personal self.

Maybe a year after this, I was watching this movie, Fierce Grace, which is about Ram Dass post-stroke. He talked about his first psychedelic experience in which he'd had an almost identical implosion of self, a disappearance of a sense of personal identity, personal history, in which his self seemed to be reduced to nothing but awareness.

As I was having this experience, I also felt this tremendous sense of well being, a much-enhanced feeling of connection to other people. I began to feel like, you, I, and everyone we know, and maybe our pets, are all basically the same at their core. So there was this much-enhanced sense of connection to other people. There was much-reduced defensiveness.

All in all, it was a powerful and liberating kind of awareness that I was able to hold onto for probably a couple of weeks; at first I couldn't stop talking about it because it was so compelling. And it seemed like the people who understood what I was talking about were people who were meditators or had some kind of spiritual practice, as it's called. And so I ended up becoming a committed meditator because it seemed to me this state of mind was devoutly to be sought. It also seemed to me that this state of mind I experienced was associated with what in the Buddhist tradition, is called mindfulness.

Meditation seems like a route to that awareness of awareness, and it seems to be a route to a capacity to be present with a modicum of acceptance. Mindfulness also fits in perfectly with the whole idea which has been so thoroughly researched in the attachment field: the idea that people's experience is changed to the extent that their relationship to their experience is changed.

DW: In the attachment research, there's been a lot of work done on the impact of the development of what's called a reflective stance–what Mary Main calls a metacognitive, and Peter Fonagy calls a mentalizing stance—toward experience. And what seems to be true is that a reflective stance toward experience buffers one against the worst impacts of trauma. This stance also seems to ultimately be capable of allowing those of us who have experienced inauspicious beginnings of the sort that might be predicted to lead to insecurity, to raise secure kids.

So a big part of the thinking that went into my book on psychotherapy and attachment was around this whole concept of a reflective, mentalizing or mindful stance as one that transforms our relationship to our experience in such a way that we are liberated from many of the constraints that are generated in the course of our personal histories. So I'd refer sort of fancifully to mentalizing and mindfulness as the double helix of personal liberation or psychological liberation.

DW: Mostly I use it indirectly. There are a handful of patients at any given time in my practice with whom I begin each session with maybe five minutes or so of meditation. There's a somewhat larger number of patients to whom I suggest that meditative practice might be of use.

DW: I think the whole matter of mindfulness is one that's almost always with me in any given session. I'm thinking about the extent to which I'm actually capable of being present with a patient at any given moment, or am I somewhere else. Is the patient present or is the patient somewhere else? I'm attempting to do what I can to be present, and I'm attempting to be mindful. And I'm attempting to do what I can to help the patient be present—also known as helping the patient to be more mindful—in the same way that I'm attempting to help people become more effective mentalizers of their own experience.

DW: Yes. Yes. Yes. It's very interesting to me that, even as we speak about mindfulness, I feel more present with the two of you.

DW: Isn't that remarkable? And when I teach about this stuff or focus in this way with a patient, it's like once I start talking about it, if I can get mindful, things change. It's a little magical.

DW: When I get mindful or when you guys get mindful, I think part of what happens is we get present. And what that means is that, among other things, subjectively speaking, the past and the future are sheared away, which I think tends to reduce a lot of anxiety, depression. Because often, where we are in the present moment is not that bad. It's not that dangerous. It's okay. So I think there's a measure of emotional or internal freedom that comes with this presence.

DW: Oh, exactly, precisely. I tend to think that as you meditate, or just have the experience over and over and over again of being present and noticing, and especially when you become aware over and over again of awareness, that has the potential to become a version of the internalized secure base.

DW: I think you'd have to look at the nature of their meditative practice. Yet, I do think that what you're talking about is a reality. In certain communities, that's talked about as spiritual bypass: they're bypassing their own internal experience by spacing out or dissociating. That's a different animal, it seems to me.

DW: Yes. Sometimes what I'll do actually between sessions is meditate for even just a few minutes. That often grounds me in such a fashion that I'm actually capable of being more present with the people with whom I'm working.

DW: There's a book that I've been asked to be part of that is going to be coming out in the future, which is called something like Clinical Pearls of Wisdom: Essential Insights from Leading Therapists, and I was asked to offer my own clinical pearls.

DW: Okay, here you go. For me, the clinical pearls are as follows: First is that the therapist's own attachment patterns are frequently, if not always, the primary influence shaping his or her potential to be of help as a therapist. In other words, our own attachment histories and the dissociations they have imposed, and the way that we have worked through some of those dissociations—all of that generates the therapist's potential to be insightful as well as vulnerable to being stuck in an impasse with a patient. So I'm talking about the centrality of the therapist's own psyche as both a facilitator of and a constraint upon what he or she is capable of doing with patients that's going to be helpful. Secondly…

DW: Sure. And I'll try not to cry. This idea became extremely vivid for me in the context of work with a particular patient with whom I had felt myself to be stuck. This was a patient with a history of trauma and some very serious obstacles that he was introducing into his own life that were very much limiting his capacity to have a decent relationship and to know himself.

At roughly the same time, I was working in my own personal therapy, in such a fashion that I bumped up against some extremely painful, difficult feelings about myself that had to do with experiences I had when I was very young—experiences that left me with a set of feelings about myself that were profoundly shameful and practically unbearable, and had me thinking some very self-destructive thoughts. And in the course of working through this experience in my own therapy, I've gotten somewhere that's been very useful.

Around the same time, I was in a peer consultation group describing my feelings of anger and envy in relation to this traumatized patient. He happened to be an extraordinarily wealthy guy who could just about do whatever he wanted to do. And one of my consultants said, “Okay, we really have a sense of what it's like for you to be with this patient, and we have a sense of who the patient is today, but you haven't said a word about his childhood, how he got to be the way he is.” And it was that question that prompted me to make bridges between my own experiences and the experiences of this patient.

As I talked about the trauma this patient had experienced as a child, I started to cry. I became aware of the ways in which I identified with this patient—how the impasse in which I found myself with him was in some ways a product of my own experiences. I didn't want to drag the patient into that particular torture chamber that I was getting to know so well.

And the rather remarkable thing is that the next time I saw the patient, practically before I could say a word, I had a sense that the encounter that we were having was occurring at a deeper level. I was able to see the patient not as somebody toward whom I felt angry and envious and whose power I was very much aware of, but instead, I was able to see the patient as a kind of scared, humiliated young kid.

The awareness of the ways in which I was avoiding—I mean, this is the nutshell version—inviting this patient into an encounter with his own feelings of shame as a function of my own difficulty moving into that terrain—that was keeping our therapy stuck. And once I began to integrate that part of myself, I was able to make room for that part of the patient in the therapy.

DW: Okay. So the second pearl is a question to ask when you are trying to figure out how your own attachment patterns are having an impact on the therapy. The question to ask yourself is extraordinarily simple: “What am I actually doing with this particular patient?” It's not always a question that you can get a complete answer to, because the answer is often hidden in the foggy realm of the dissociated, but I think you can certainly see the tip of the iceberg when you ask yourself, “What am I actually doing with this patient?”

I think the literature on enactments often focuses on what it is about the patient that is being enacted that's hooking something in the therapist. What I'm suggesting is there's a much more direct route to understanding what's going on in our enactments with our patients, which is simply to ask ourselves, “What am I actually doing with this particular patient?”

And then the third pearl is that often getting into a mindful state of mind is an aid to answering that question in a productive fashion. If you can actually get present and ask yourself, “What am I doing with this patient?” often there's a clarity that wouldn't otherwise be available to you.

DW: Thanks, yes, we got to a lot.