Wallin15 reports that a level of consistency was found between behavior observed in infancy and attachment styles in adulthood in up to 75% of subjects studied longitudinally. More important, research has demonstrated that many adults with histories that would predict insecure attachment behaviors have reparative experiences later in life with significant others that allow for “earned secure” attachments. Sensitivity, availability, and responsiveness are at the core of all psychotherapeutic interventions and enduring life-enhancing relationships.5,15,16
Ciechanowski and colleagues11-13 examined correlations between attachment styles and treatment adherence and hypothesized that certain adult attachment styles correlate with treatment adherence in the medically ill. They studied cohorts of diabetic patients in primary care clinic settings, a high-risk population because nonadherence to treatment among diabetic patients is associated with significant morbidity and mortality. The initial hypothesis was that only those with secure attachments would be treatment-adherent. However, the findings were surprising and indicate that 1 attachment style correlates with nonadherence, 1 correlates with adherence, and 2 are not significant. They found that persons with dismissing attachment style had significantly worse glucose control than those with secure, preoccupied, or fearful attachment styles.
Dismissing individuals, such as infants who do not protest when separated from parents and who are indifferent to their return and are inhibited at play, as adults become compulsively self-reliant and are uncomfortable being close to or trusting of others. Narratives of dismissing individuals are characterized by a very brief discourse, gross generalizations, a paucity of examples, unsupported claims (even active contradictions), and an insistence on absence of childhood memories. They idealize or devalue one or both parents but are usually unable to substantiate their claims.
Adults with secure attachment experienced consistently responsive caregiving parents, while adults with dismissing attachment had avoidant parents who were consistently emotionally unresponsive. Adults with secure attachment are comfortable depending on others and are readily comforted by them. Adults with dismissing style become compulsively self-reliant, describe themselves as independent and self-sufficient, and are uncomfortable being close to or trusting of others. Dismissing patients, while initially unable to remember, describe, emote, or reconstruct experiences, can be gradually exposed to these processes by a psychodynamically informed therapist.
Awareness of dismissing attachment behaviors in our nonadherent patients can help us reframe our psychotherapeutic work. Wallin15 describes the process of therapeutic interventions with dismissing individuals as “moving from isolation to intimacy.” In the early stages of treatment, he encourages a keen awareness of subtle affective cues and nonverbal communication, and judicious sharing of coun-tertransference, to help patients be comfortable in letting others in and in being treatment collaborators.
The dynamics of power struggles and control need to be clearly understood by the therapist, and a warm, collaborative, and cooperative stance is preferred to an authoritarian and detached attitude. Attachment theory and research provides a useful framework for understanding the impact of parent-infant caregiving on development and subsequent adult patterns of relationships. Psychotherapy interventions based on attachment theory for parents with insecure caregiving styles can promote parental sensitivity and secure attachment organization. Similarly, psychotherapy interventions informed by the contribu-tions of attachment theory could help adults with dismissing attachment behaviors who are nonadherent to treatment by stressing the importance of collaborative relationships, relinquishing excessive self-reliance and control, and promoting trust.