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Patient alliance key in attachment therapy: positive transference important.

LOS ANGELES -- The challenge in attachment therapy is to form a therapeutic alliance with a patient who finds it difficult to establish trusting relationships, Allan Schore, Ph.D., said at a conference on attachment theory sponsored by the University of California, San Francisco.

Effective therapy relies heavily on the spontaneous, nonverbal transference and countertransference of feelings between patient and therapist, Dr. Schore said.

Attachment therapy focuses on the right hemisphere because that's where attachment functions--including the nonconscious processing of social and emotional information--are coordinated. In preverbal children, interpersonal experiences affect right-brain maturation, which is essentially complete by 3 years of age, so abuse or neglect can have lingering mal-adaptive effects on right-brain function.

Because right-brain interaction relies on nonverbal communication, the therapist must receive and interpret those signals from the patient and send out signals suggesting that the patient can feel safe in expressing his or her trauma. That means "the deeper layers of the therapist's psyche must be open to stimuli that emanate from the patient's communications," said Dr. Schore of the University of California, San Francisco.

A strong therapeutic alliance helps restore normal right hemispheric activity and so is essential for a successful outcome, he said. "In this way, the emotional relationships forged during the process of psychotherapy are covering the deficiency caused by the lack of emotional relations in early childhood."

Body language and facial expressions are powerful, nonverbal ways of communicating various messages to patients. Patients with attachment disorders are extremely sensitive to cues conveyed through facial expression, although much of this information is processed by the right brain on a subconscious level.

Dr. Schore cited Dr. Antonio R. Damasio, who explained that when interpreting other people's facial expressions, humans subconsciously try to determine how they would feel when displaying those expressions. So if a patient's right brain reads the therapist's expression as trust, the patient will feel safe in the therapeutic alliance, and consequently will feel more confident in taking on novel experiences and emotions.

This also will help patients get in touch with their own feelings, because they'll learn that "understanding other minds is important, but also understanding [their] own mind can be an important source of knowledge about others."

Attachment therapy can be adapted to short-or long-term treatment. The goal of short-term therapy is to return the patients to their premorbid attachment pattern so that they are able to develop more salutary attachments. Long-term therapy picks up where short-term therapy leaves off by guiding the patients through that reorganizing process and helping them to attain a secure pattern of attachment.

Frequently overlooked is the therapeutic impact of positive emotional experiences, Dr. Schore said. They allow the patients to feel safe enough to delve more deeply into their psyches and reveal aspects of themselves that have been closed off.

Evidence is now accruing that effective treatment can, in fact, "rewire" the brain.

In patients with social phobia presented with a stressful public speaking task, successful treatment with citalopram or group cognitive--behavioral therapy was associated with a decrease in blood flow to the amygdala, hippocampus, and the periamygdaloid, rhinal, and parahippocampal regions of the cortex, when compared to a control group of patients who were placed on a treatment waiting list (Arch. Gen. Psychiatry 59[5]:425-33, 2002).
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Title Annotation:Adult Psychiatry
Author:MacReady, Norra
Publication:Clinical Psychiatry News
Date:Oct 1, 2003
Words:543
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