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The Re-Attachment EditionThe Re-Attachment Edition
6262
New TherapistNew Therapist
Indispensable survival guide for the thinking psychotherapist July/August 2009
Close but not too close
The plight of the avoidantly attached
partner in couples therapy
Good for who?
Differential
susceptibility
to therapy
10 New Therapist 62, July/August 2009
"I want you in the house, just not in
my room... unless I ask you"
of the avoidantly attached
partner in couples therapy
By Stan Tatkin
of the avoidantly attached
partner in couples therapy
By Stan Tatkin
11
New Therapist 62, July/August 2009
The avoidantly attached baby quietly
suffers from pervasive attachment
insecurity, rooted in interpersonal
neglect, and adapts by creating a quasi-
independent internal working model.
The greater the adaptation, the more the
adult avoidant appears to the outside
world as a person who does not need
others and who functions autonomously.
In fact, the undefended avoidant feels
desperately alone, isolated, and unable
to depend fully on a primary attachment
figure. The individual or couples
therapist must quickly connect with the
avoidant’s implicit fears and convert
his or her ego-syntonic adaptation into
therapeutic doubt and curiosity.
The purpose of this article is to help
the therapist understand the avoidant
adult’s dilemma in primary attachment
relationships and point toward effective
interventions that might facilitate
the therapeutic process. The ideas
in this article do not necessary apply
equally to all avoidant subtypes. For
instance, the somewhat rare Ds1, as
classified in Main’s Adult Attachment
Interview (2000), completely minimize
attachment, even to the extent of
denying any attachment at all. The Ds2,
the most devaluing subtype, and the
Ds3 both entertain their attachment,
albeit minimally. Although I address
the avoidant proper, it should be noted
the characterizations here also apply to
the more avoidant subtypes within the
secure classification.
In a World of Their Own
Similar to people suffering from
narcissistic or schizoid personality
disorders, the avoidant is caught
between interpersonal and intrapersonal
worlds, between fear of isolation and
fear of neglect or maltreatment. From
an attachment perspective, the internal
working model of the avoidant infant
(A1 or A2 subtype) develops in response
to its dismissive caregiver (Ds2 or Ds3
subtype). These infant-caregiver pairs
typically show low levels of proximity
seeking and contact maintenance while
together, during separation, and during
reunion. Avoidant children display
more low-keyed Behaviour, more gaze
aversion, and more pulling away than
do secure and angry/resistant children.
They may show directed Behaviour,
such as proximity seeking toward
strangers, but drop these Behaviours
with their primary caregivers. Avoidant
children often go unnoticed because
they are considered “good” and “well-
behaved” and “never a bother.” By all
appearances, the avoidant child seems
independent; however, this appearance
of autonomy is the child’s adaption to
his or her caregiver’s low valuation of
attachment Behaviours. One can argue
that independence cannot be achieved
by way of neglect.
From a psychobiological perspective,
the avoidant child lacks continual
interaction with caregivers, and so
settles into a form of self-stimulation
and self-soothing called autoregulation.
This turning to the self for all things
foreshadows future relationship troubles
on a variety of levels, most of which
involve approach by a primary attachment
figure. The following sections focus on
the problem of approach, as experienced
by the adult avoidant individual.
Intrusiveness
Autoregulation tends to be a dissociative
state, requiring little interaction and
therefore causing little interpersonal
stress. The autoregulatory play state,
which involves positive affects, operates
on a timeless, spaceless continuum
undisturbed by time-bounded, space-
bounded reality. In adults, this presents
a problem of intrusiveness whenever the
autoregulatory state is interrupted by
a primary attachment figure (i.e., lover
or spouse). The approach of a primary
figure disrupts the autoregulatory state,
causing a fundamental adaptation much
like that experienced during childhood.
The avoidant’s rejection of the partner’s
approach is not so much antisocial as
it is energy conserving because the
avoidant is simply trying to maintain
psychobiological homeostasis.
The couples therapist can capture
autoregulatory issues by observing
couples work, uninterrupted, on a conflict
toward a satisfying solution, even if it is
temporary. Instead of tracking the content
of their conflict, the therapist tracks
moment-by-moment psychobiological
shifts and changes within and between
partners. These changes are observed in
the partners’ faces, bodies, movements,
vocal intensity, and prosody. The therapist
also tracks the wave-like variations of
each partner’s arousal, which either
increase or decrease as each is stimulated
and calmed.
"The undefended
avoidant feels
desperately alone,
isolated, and unable
to depend fully on a
primary attachment
figure."
12 New Therapist 62, July/August 2009
The autoregulating partner (the avoidant) will appear less
expressive, less verbal, more emotionally restricted, and
less able to co-regulate than the partner, who will provide
calmness or stimulation, as needed by the partner. The
avoidant’s memory of events may differ greatly from that of
the partner; the events the avoidant remembers may be devoid
of emotional value or importance, at least in comparison with
what the partner recalls. The avoidant’s gaze often is averted
away from the partner’s eyes and may appear low key and
under-responsive (withdrawal) or explosive and over-reactive
(attack). It is common to observe the avoidant drifting off
when his or her partner takes centre stage for longer than
brief moments. This can be due to early experiences of feeling
“talked at” by primary caregivers or invisible in the presence
of caregivers who took centre stage.
The therapist can help both the avoidant and his or her
partner understand that true mutuality and inclusion are
foreign to the avoidant, who believes he or she is only needed
and never really wanted. Feeling needed but not wanted is a
central attachment injury for the avoidant, who had to adapt
to a non-reciprocal, dismissive, or derogating caregiver.
Psychoanalytic literature has long described the exploitation
of the narcissistic child and the master/slave relationship
with the schizoid child (Freud, Sandler, Person, & Fonagy,
1991; Guntrip, 1969; Klein & Masterson, 1989; Kohut, 1977;
Masterson, 1981).
Startle/Attack
Another problem closely related to intrusiveness is the
avoidant’s experience of startle and attack with the sound and
sight of an approaching primary figure. The autoregulatory
state is dissociative, energy conserving, and non-interactive.
On a neurological level, brain metabolism is low, as is demand
for the brain’s resources. Interaction requires greater central
and peripheral nervous system activation, and therefore can
be experienced by the avoidant as having to “wake up,”
as if from a deep sleep. The avoidant may feel startled or
attacked in response to the sound of an approaching voice or
the visual of an approaching person, or for that matter, the
experience of an approaching interpretation by a therapist.
The avoidant’s reflex may be anger; dismissal; withdrawal;
and of course, avoidance.
The couples therapist can use any number of physical
exercises that move partners together and apart so that
the couple can experience and the therapist can view their
immediate bodily reactions to approach and withdrawal. In
my practice, I use a formalized, structured exercise wherein
I have partners stand and move toward and away from one
another (Figure 1). I also use video recording and playback
so couples can see immediate reactions in the face, eyes,
posture, and skin color, and see other physiological cues
of stress and anxiety. I find these exercises go a long way
toward helping convince partners of their psychobiological
reactions to one another and toward understanding that
these reactions are immediate, predictable, and reproducible.
I also find it important to tie these psychobiological reflexes
to their attachment history (see attachment interview) and
to current issues with approach, physical proximity, and
distance.
Figure 1
13
New Therapist 62, July/August 2009
Switching States
One problem that pertains to both intrusiveness and startle/
attack is the avoidant’s difficulty with switching states.
Secure individuals can switch easily between autoregulation
and interactive regulation with another person. Interactive
regulation is characterized by focused and sustained
interactive play that involves face-to-face, eye-to-eye, and
perhaps skin-to-skin contact with at least one other person.
Secures are accustomed to moving between these two states
without anxiety or depression because both states are
pleasurable and because the transitions between them are
pain free. However, avoidants are rooted in an autoregulatory
strategy and are unaccustomed to switching between self-
play and interactive-play. For them, the ball naturally rolls in
the direction of self-play as a default, and does so without
any awareness of it on their part.
The avoidant, for example, may show initial resistance
when a partner makes a bid for interaction. However, after
becoming acclimated to interactive regulation, the avoidant
may show no signs of discomfort or interest in returning to
autoregulation. Not surprisingly, though, if the avoidant
is left alone for several minutes, the ball rolls back into
autoregulation and the resistance to interact on can quickly
reappear, leading to a renewed period of acclimation. Again,
the avoidant is unaware of the immediate drift back into
autoregulation, but is aware of the intrusion by the partner,
who stands mystified and even miffed by the rapid, inexplicable
shift away from interaction.
Therapists can look for instances in the couple’s narrative
that point to this kind of problem and help educate them and
normalize this issue for them. Chances are very good neither
partner will have focused on this issue in this particular way.
Non-Mutuality
The other problem with approach for the avoidant refers
back to the attachment injury with the early primary
attachment figure. Because the avoidant is born out of a
dismissive/derogating parenting style, the basic experience
of relationships as non-mutual becomes concretized in early
childhood. The dismissive parenting style values things and
self over relationship and attachment. Although secures do
not always value attachment and relationship, mostly they
do. In all relationships, what is ultimately important is the
degree and frequency to which a partner makes relational
versus non-relational choices on a day-to-day basis.
A one-person psychological system can be defined as
one in which little or no true mutuality exists. Personality
disorders are one-person psychological systems because true
mutuality is a non-existent feature of that internal object
relational world. For a variety of reasons, constitutional
and/or relational, personality-disordered individuals suffer
pre-oedipal wounds that sometimes permanently delay the
formation of whole object relations. Attachment injuries
derived from constitutional and/or relational etiologies
also involve childhood organizational adaptations to either
insensitive or frightening caregivers. The experience of true
mutuality is replaced by basic insecurity about the self and
other; the attachment relationship is not safe or secure and it
is not held together as much by attraction as by fear, either
of loss of self or loss of other.
The avoidant bristles in response to an approaching
primary attachment figure because he or she does not believe
in mutuality. The approaching figure wants something from
him or her, and reciprocity is not possible. This leaves
the avoidant in a dilemma that can only be resolved with
compliance, withdrawal, anger, or avoidance. The avoidant
experiences shame and fear with the emergence of aversion
toward the primary attachment figure. He or she fears the
other will recognize this aversive reaction, and because the
cause of this reaction is a mystery even to the avoidant, the
experience is one of shame: “There is something wrong with
me.”
Insight for the avoidant is notoriously poor, and problems
with autobiographical memory and somatoaffective awareness
are noted (Fukunishi, Sei, Morita, & Rahe, 1999; Guttman &
Laporte, 2002; Larsen, Brand, Bermond, & Hijman, 2003;
Main, 2000). The avoidant’s declarative memory is filled with
ideas about parents and childhood, but lack autobiographical
memories filled with the experience of parents and childhood.
Most often, the avoidant’s report is idealized, lacking in
detail, and superficial. For this reason, the avoidant is largely
unaware of his or her attachment dilemma, and because
adaptation has been so complete, he or she does not appear
distressed and tends to see nothing wrong with his or her
avoidant strategies.
“I Want You in the House, Just Not in
My Room... Unless I Ask You”
The avoidant wants to feel securely attached, but tends to
form attachments that are pseudosecure. The avoidant wants
to know a primary attachment figure is around, but does
not want to be approached unless invited. This is because
approach by the other is experienced as a threat, something
that does not occur when the avoidant makes the approach
himself or herself. It is as though the avoidant is saying,
“I want you in the house, just not in my room. And you
can only come into my room when I extend the invitation.”
This particular feature generally does not appear during the
courtship phase of romantic relationships. However, as the
relationship begins to appear more permanent and settled,
approach issues become evident in areas concerning time
(interaction), space (proximity), and sex (libido).
The avoidant’s pseudosecurity is rooted in a fantasy of
omnipresence and permanence. This fantasy allows the avoidant
to spend extended time away from the primary figure, without
awareness of separation or loss. In the avoidant’s mind, the
other partner is always there, is always around, and will never
leave them. This notion of omnipresence, while comforting
in one sense, is smothering and intrusive in another, which
then leads to more avoidant Behaviour and devaluation of the
partner.
The avoidant’s fantasy of omnipresence is yet another
challenge to the couples therapist because the avoidant
partner is unaware of his or her extreme dependence on the
other. The therapist may not see the extent of this dependency
until after the avoidant has been left, unequivocally, by the
partner. When this occurs, the avoidant may collapse in an
anaclitic depression unlike any he or she ever experienced
before. This is because, in childhood as in adulthood, neglect
14 New Therapist 62, July/August 2009
does not equal abandonment for the avoidant. Although
the avoidant’s early caregiver may have been neglectful,
insensitive, or disappointing, the caregiver was always there.
The same is true for the adult relationship: no matter how
disappointing the partner may be, he or she is experienced
as always there. This is why the incontestable departure of a
partner can come as an unexpected blow to the avoidant.
Therapeutic interventions should be aimed at penetrating
the fantasy of omnipresence and permanence. Only through the
dissolution of this defense can the avoidant truly appreciate,
value, and move toward his or her primary attachment figure.
In this case, healthy fear of realistic loss helps counteract
the avoidant’s pseudosecure strategies. I have used death and
dying suggestions and exercises to facilitate the awareness of
impending loss through illness, death, or other unexpected
conditions that would result in the loss of the other. Still,
the reader should be aware that, in severe cases of avoidance,
even the most potent attempts to interrupt the avoidant’s
fantasy of omnipresence and permanence will be thwarted by
the avoidant’s denial of loss.
Brief Separations Without Distress
All couples go through periods of brief or extended
separations in the course of their relationship. Separations
can result simply from going to work or school daily or can
be associated with trips, either personal or business. It may
seem contradictory to say the avoidant is highly distressed in
anticipation of and upon separation from his or her primary
attachment figure, especially because I just described how the
avoidant avoids loss by using pseudosecure strategies (e.g.,
a fantasy of omnipresence). However, the avoidant’s defense
is so rapid and effective that he or she is unaware of distress
when he or she must physically separate for a day, several
days, or a week. The shift to autoregulation is immediate,
and so the partner’s exit allows the avoidant to make an easy
transition. The avoidant may claim to feel relieved or excited
by brief or even extended separations.
If the therapist queries how well the avoidant fares in the
partner’s absence, such as by asking about sleep and eating and
other self-care habits, the difference between self-regulatory
efficacy with and without the partner can be surprising.
For instance, one partner admitted he did not get himself
to bed regularly when his partner was not there. His eating
habits worsened, as did his time management. This came as
a surprise to both partners, who always assumed he did quite
well alone. In general, therapeutic progress for the avoidant
is evident through increased awareness of somatosensory,
somatoaffective cues of distress upon separation from his or
her primary attachment figure.
Treatment Approach
The Psychobiological Approach to Couples Therapy™ (PACT)
focuses on early attachment and its effect on brain and nervous
system development, as well as on specific neuroendocrine
issues related to interpersonal stress. Four primary domains
drive the approach: attachment, arousal, developmental
neuroscience, and therapeutic enactment. What follows is
a brief set of interventions and goals to use for avoidant
partners in each domain.
Attachment
The couples therapist should use some formal variation of
an attachment interview, with both partners present in one
session. A well-designed, disciplined interview, such as the
one I use in my practice, can help the therapist expose the
avoidant’s early neglect history and lifelong struggle with
attachment relationships (Tatkin, 2007). I use an abbreviated
version of Main’s Adult Attachment Interview (Hesse, 1999),
which was originally developed as a research or assessment
tool, as an intake device that serves as an intervention
contrivance.
The therapist must create enough therapeutic doubt
and curiosity early in treatment to get the avoidant partner
invested in therapy. The avoidant always requires proof, and
a competent attachment interview can provide the emotional
experience necessary to convince the avoidant (and partner)
that things are not what they seem. A proper attachment
interview is extraordinarily stressful and often quite depressing
for the avoidant. For this reason, it is important to allow
enough time to fully carry out and interpret the procedure for
both partners, and to deal with any fallout.
In this domain, the therapist should expect the following
treatment goals with the avoidant partner:
He or she will able to convert maladaptive avoidant {
defenses from ego-syntonic to ego-dystonic.
He or she will become aware of his or her own internal {
working model (avoidant organization).
He or she will cease all explicit and implicit threats to {
the couple’s safety and security system (this system scaf-
folds both partners and makes possible personal growth
and development).
He or she will accept and be willing to make some coun- {
terintuitive Behavioural changes (e.g., make approaches
when preferring to withdraw; make proactive elective
bids for connection with the partner; set pro-relationship
boundaries and limits; and make quick and effective repairs
to the relationship when a breach occurs, especially when
the breach is due to avoidant strategies).
Arousal
This domain pertains to the autonomic nervous system (ANS)
and its entrenchment in the internal working model. Because
the ANS is intricately associated with emotional experience
and expression, arousal and affect regulation are considered
here as interchangeable. The therapist collects a history on
each partner’s capacity to self-regulate and interactively
regulate with the other. Self-regulation pertains to a partner’s
ability to manage his or her own arousal (level of stimulation)
in such a way that he or she maintains a pro-relationship
mental/emotional condition adequate for relating to the
other partner. Self-regulation skill is assessed by observing
each partner’s ability to manage fear and threat without going
into hyperarousal (fight/flight/freeze) or hypoarousal (energy
conservation withdrawal), two extreme arousal states that
lead to anti-relationship Behaviour. Interactive regulation
is the couple’s capacity to co-manage positive and negative
arousal states, acting as stewards of the intensity and duration
15
New Therapist 62, July/August 2009
of their positive and negative emotional states.
The therapist observes the couple in real time as the
partners work any conflict toward a solution. The therapist
tracks the couple as a regulatory team, moving in and out of
various mental and emotional states, and notices if or when
partners become overwhelmed by either too much positive
or too much negative experience, and notices if they do
anything about it, what they do, when they do it, and
how effective they are at restoring emotional equilibrium.
Poor self-regulation makes more difficult the prospect of
effective interactive regulation. One partner is often better
at interactive regulation, and
sometimes is much better
than the other partner. One
partner’s skillfulness can
sometimes but not always
compensate for the other’s
deficits in self-regulation.
As mentioned earlier, the
avoidant gravitates toward
autoregulation, an inherently
non-relational practice. This
often leads to problems
with the couple’s interactive
regulatory practices. The
couples therapist must pay
special attention to the
avoidant’s nonverbal arousal
cues that suggest either
hyperarousal or hypoarousal
and intervene in ways
that increase the couple’s
skill at co-regulation. This
often is best achieved
through increasing each
partner’s moment-to-moment
awareness of nonverbal cues,
especially concerning distress
or injury, and improving their
ability to quickly administer
relief to one another. As with
distress cues, partners must
learn how to recognize relief
in one another to gauge the
success of their attempts to
soothe, console, and repair.
In this domain, the therapist should expect the following
treatment goals with the avoidant partner:
He or she will become aware of interoceptive (body) cues {
that alert him or her to his or her own ANS state.
He or she will be better able to tolerate and manage {
negative states without going into either hyperarousal or
hypoarousal.
He or she will no longer freeze, still, or under-respond {
while interacting with his or her partner; under-respond-
ing is gauged by nonverbal Behaviours (e.g., a lack of
vocalizations, facial motility, eye contact, movements, or
gestures).
He or she will become a better co-regulatory partner. {
Developmental Neuroscience
This domain is interrelated to attachment and arousal
because early attachment affects and is affected by the early
development of basic regulatory functions and of critical
brain structures and neuropathways, the maturation of
which are experience dependent. Avoidant’s social-emotional
deficits, which can be observed in the areas of empathy,
accurate reading and responding to social-emotional cues,
alexithymia, theory of mind, and attachment formation,
point to neurological deficits
in the right hemisphere
and frontolimbic circuits. A
psychobiologically oriented
therapist must consider
social-emotional deficits
and explore whether or not
these deficits are specific and
limited to partner interaction
and interpersonal stress, or
possibly indicate neurological
issues of an organic or
developmental nature.
In this domain, the
therapist should expect the
following treatment goals
with the avoidant partner:
He or she will cease to
make misappraisals of the
partner’s mal-intent, in light
of any uncovered of deficits,
and will adjust his or her
expectations accordingly.
He or she will develop
neurologically with the help of
partner interactions, partner
support, and the reduction
of interpersonal pressure to
perform beyond his or her
capacity in identified areas.
Therapeutic
Enactment
Finally, this domain is the
therapeutic component that ties it all together. A successful
psychobiological approach to couples therapy must ultimately
focus on partner experience, not ideas. Psychobiological
systems are generally implicit in nature; that is, nonverbal
and often non-conscious. Psychobiological processes are
reflexive, automatic, and extremely fast. A couple’s narrative,
or the cognitive content of their distress, is only the tip of
the iceberg. What lies below is the often incoherent, implicit
account of their real distress—the things they cannot name
or describe, but that they experience and act upon, often
inexplicably. For this reason, the couples therapist must set
the stage to observe and work with interpersonal stress,
attachment insecurity, arousal dysregulation, and social-
emotional disability.
Stan Tatkin, PsyD, MFT, founder/developer of A
Psychobiological Approach To Couples Therapy™,
integrates neuroscience, infant attachment, arousal
regulation, and therapeutic enactment applied to
adult primary attachment relationships. He main-
tains a practice in Calabasas, California, and runs
a bi-weekly clinical study group for medical and
mental health professionals (www.ahealthymind.
org/csg) and training programs in Seattle and San
Francisco.
16 New Therapist 62, July/August 2009
To accomplish this task, the therapist and couple must
have enough time. Therapy sessions cannot be only one hour,
but may require two, three, or even four hours to accommodate
the various emotional states through which the couple will
pass, aided at times by therapeutic provocation.
The therapist needs to enact dysregulating events in real
time for the couple to help them while in various mental and
emotional states. Simply talking about what happens will
be of little use to the couple after they leave the session.
Couples in distress frequently move into emotional/mental
states they cannot manage without employing defensive,
pro-self, anti-relationship strategies, often with devastating
results. The therapist will err if he or she follows a cognitive
or problem-solving approach because this is not a problem of
ideas, values, and principles, but a crisis of two brains and
two nervous systems unable to mollify threat.
In this domain, the therapist should expect the following
treatment goals with the avoidant partner, all of which will be
demonstrated during therapeutic enactments:
He or she will be able to enter any couple-focused conflict {
without fear of becoming overwhelmed or defeated.
He or she will know the three or four things that can {
quickly and effectively calm and relieve his or her partner
most of the time.
He or she will know the three or four things that will {
quickly and effectively excite or please his or her partner
most of the time.
He or she will be able to do what is necessary to quickly {
and effectively short-circuit any mounting threat to the
couple’s safety and security system.
Conclusions
The avoidantly attached romantic partner can be characterized
as someone who adapted in childhood to neglectful, insensitive
parenting by turning inward and away from sustained,
mutually rewarding interactions with primary others. Part of
this turning away came from psychobiological adaptations to
caregiver disregard of attachment values and true mutuality,
and another part came from spending too much time alone.
Despite these adaptations, the avoidant craves relationship and
interaction (as do secures), but suffers from issues surrounding
approach by a primary attachment figure, such as sensitivity
to intrusion, feeling startled and attacked, having difficulty
switching between states of aloneness and interaction, and
feeling used. Contradictory desires for connectedness and
freedom from engulfment are held together by a pseudosecure
fantasy of partner omnipresence and permanence. This
fantasy allows the avoidant to separate from his or her partner
without awareness of loss because the partner’s permanent
presence is taken for granted. However, it also exposes the
avoidant to unwanted advances and intrusions by his or her
partner, whose intent is to make one-sided, non-reciprocal
demands. The avoidant is largely unaware of the price of his
or her adaptation and generally remains in denial of his or
her inability to reconcile contradictory dependency needs and
fears.
The couples therapist must gain a therapeutic alliance
from the onset of therapy by penetrating the avoidant’s
defensive system. This is most effectively accomplished
by administering an abbreviated, clinically-oriented Adult
Attachment Interview (Tatkin, 2007) as an intake device, with
both partners present and within the span of one session. This
abbreviated interview is intended to serve as an intervention,
rather than an assessment. The PACT approach (Tatkin &
Solomon, in preparation) is particularly useful in treating
avoidant partners and couples, and employs experience-based
tools and techniques to effect and alter implicit, nonverbal
intersubjective systems. Moreover, this approach helps the
couples therapist understand the developmental vicissitudes
of the avoidant partner, which helps point treatment
interventions in the right direction.
References
Freud, S., Sandler, J., Person, E. S., & Fonagy, P. (1991).
Freud's "On narcissism: An introduction." New Haven, CT: Yale
University Press.
Fukunishi, I., Sei, H., Morita, Y., & Rahe, R. H. (1999).
Sympathetic activity in alexithymics with mother's low care.
Journal of Psychosomatic Research, 46(6), 579-589.
Guntrip, H. J. S. (1969). Schizoid phenomena, object-relations,
and the self. New York: International Universities Press.
Guttman, H., & Laporte, L. (2002). Alexithymia, empathy, and
psychological symptoms in a family context. Comprehensive
Psychiatry, 43(6), 448-455.
Hesse, E. (1999). The adult attachment interview: Historical
and current perspectives. In J. Cassidy & P. R. Shaver (Eds.),
Handbook of attachment: Theory, research, and clinical
applications (pp. 395-433). New York: The Guilford Press.
Klein, R., & Masterson, J. F. (1989). Psychotherapy of the
disorders of the self: The Masterson approach. New York:
Brunner/Mazel.
Kohut, H. (1977). The restoration of the self. New York:
International Universities Press.
Larsen, J. K., Brand, N., Bermond, B., & Hijman, R. (2003).
Cognitive and emotional characteristics of alexithymia: A
review of neurobiological studies. Journal of Psychosomatic
Research, 54(6), 533-541.
Main, M. (2000). The organized categories of infant, child,
and adult attachment. Journal of the American Psychoanalytic
Association, 48, 1055-1096.
Masterson, J. F. (1981). The narcissistic and borderline
disorders: An integrated developmental approach. Larchmont,
NY: Brunner/Mazel.
Tatkin, S. (2007). Attachment interview for couples.
Unpublished manuscript. University of California at Los
Angeles, Department of Family Medicine, David Geffen School
of Medicine.
Tatkin, S., & Solomon, M. (in preparation). Love and war in
intimate relationships: How the mind, brain, and body interact.
New York: W. W. Norton.
