Psychosocial Interventions
The dyadic nature of psychotherapy leads us to predict that attachment styles can affect psychotherapy effectiveness. Conversely, attachment styles can change: several studies have shown that psychotherapy can render attachment style more secure (
70–
72). Indeed, attachment can differ among various dyads for the same individual, although formative early dyadic models strongly influence later central attachments.
Key active ingredients of psychotherapy include the capacities to trust, to share, and to feel soothed by the therapist (
71). Psychotherapies differ in their degree of focus on attachment and separation-sensitive social schemata. Behavioral therapies for anxiety tend to focus on the fear extinction paradigm (
73) rather than attachment per se. In contrast, psychodynamic and interpersonal psychotherapies for anxiety focus on relationships and associated affects. These therapies actively address improving patients’ capacity for reflection and helping them to recognize and tolerate emotional responses and perceived dangers surrounding attachment (
69). Therapists attuned to patients’ separation fears may detect them in the transference or in outside relationships and can use dynamic or interpersonal approaches to articulate and help patients to better understand them, thereby decreasing their intensity. This work presumably increases patients’ reflective function (
74). A putative mediator of affect-focused psychotherapies, reflective function measures emotional understanding of one’s formative relationships and one’s own and others’ attachments and emotions (
75). Reflective function studies may be useful in delineating mechanisms of change occurring in psychiatric symptoms through modulation of attachment and reflection (
74–
76).
Affect-Focused Psychotherapies Targeting Separation Anxiety
The negative impact of separation anxiety and panic spectrum symptoms on the outcomes of treatment for mood and anxiety disorders suggests that research should evaluate psychotherapy interventions targeting relationships, attachment, and associated affects. Indeed, the potency of separation anxiety argues for developing better-tailored treatments across disorders (
49,
77). We highlight two small pilot psychotherapy trials in which some of us were involved.
Cyranowski et al. (
77) treated 18 subjects with primary major depression and high levels of lifetime panic spectrum symptoms (
35) in an open trial of interpersonal psychotherapy adapted to focus on depression, anxiety, and anxious avoidance. Fourteen (78%) subjects met remission criteria after 12 weeks, with improvements (p<0.0001) across all measured domains: depression, anxiety, and psychosocial functioning. A randomized trial comparing this treatment with supportive therapy is further evaluating this approach.
In another study, 49 adults with primary panic disorder with or without agoraphobia were randomly assigned to panic-focused psychodynamic psychotherapy (
78) or to applied relaxation training (unpublished manual of J.A. Cerny et al., 1984), an efficacious non-separation-anxiety-focused intervention for panic disorder (
79). The principles of panic-focused psychodynamic psychotherapy emphasize free association, centrality of the transference, and unconscious thoughts underlying physical sensations of panic and difficulty with separation and autonomy. The therapist focuses on these processes as they relate to panic symptoms. Common themes of difficulty with separations and unconscious rage inform interpretive interventions. Panic-focused psychodynamic psychotherapy, as an affect-focused psychotherapy, specifically targets separation anxiety as a core component of understanding panic; patients’ high separation anxiety levels constitute a central organizing element in their self-view as incompetent and unable to manage developmentally normative tasks without the presence of their central attachment figures. The inevitable repetition of this dyadic pattern with the therapist within a time-limited 24-session, 12-week format heightens the opportunity to work with separation anxiety and permits the reexperiencing and better understanding in verbal form of this affectively charged paradigm (
7,
78).
Eleven of 23 patients receiving applied relaxation training (48%) and 15 of 26 in panic-focused psychodynamic psychotherapy (58%) had high baseline levels of current separation anxiety and panic spectrum symptoms, i.e., a score of 35 or higher on the Panic-Agoraphobic Spectrum Self-Report (37). A significant interaction between treatment and baseline score predicted panic symptom improvement at treatment end (b=−11.0, t=−3.68, df=44, p<0.001), indicating that baseline severity of separation anxiety moderated the effect of panic-focused psychodynamic psychotherapy on panic symptoms. Panic-focused therapy had significantly greater efficacy than relaxation training among patients with high levels of separation anxiety. Thus, patients with primary panic disorder with higher baseline separation anxiety levels responded particularly robustly to panic-focused psychodynamic psychotherapy, but not to applied relaxation training.
When Lena began panic-focused psychodynamic psychotherapy, she needed a friend to accompany her from a distant suburb because of her terror of traveling alone. The therapist first explored Lena’s worst panic attacks, which had occurred in cars when she was in the midst of deciding to break up with her last serious girlfriend. During panic attacks, she felt terrified and completely isolated, as if her car were a “tomb” and “as though I’ll never see anyone I love again.”
The therapist helped Lena to begin to trace an emotional line between her fury at her abusive ex-girlfriend and her plan to leave her, her subsequent physical sensations of overwhelming anxiety, her sense of loss of executive control as highlighted by her relatively new inability to drive, and her central fantasy of her car as a tomb, separating her forever from the people she loved, especially from her mother. In carefully delving into the complicated, ambivalent, yet intense and dependent relationships she tended to form, the therapist explored an emerging core fantasy Lena had about herself that fueled much of the intensity of her relationships: that she was incompetent and unable to manage situations that might arise (on the train to appointments with her therapist, for example).
Lena relinquished her travel companion and began traveling and attending sessions alone by session 5. She rapidly resumed driving and no longer felt so isolated in her car or as though she would panic. The therapist continued to pursue Lena’s core fantasy that she was incompetent like a small child and terrified to be apart from her mother, as she had been when she was very young, and that therefore she was unable to handle matters that might arise at night if she were to sleep alone without her new girlfriend. After session 11, Lena slept alone for the first time in her life.
The therapist helped Lena to verbally articulate how her strength and newfound independence were associated with her relationship with the therapist, something she would have to relinquish soon because of the (24-session) study time limit. Lena actively mourned the loss of her therapist, experiencing “jumpy nerves” on the train when coming to see her, resisting a “pull” to “pick up women to make it better,” and later expressing anger and sadness that the therapy could not continue. She said that she had never said goodbye as she was now in parting with the therapist, permitting herself to feel the sadness of the loss without becoming overwhelmingly anxious and frantic to replace the therapist with new “emergency” relationships. Despite tremendous anticipatory anxiety, Lena felt calmer and more comfortable: traveling, working, and attending school without anxiety at termination. She had ended her relationship with the new girlfriend after session 17 and despite feeling “lonely and unusual,” had very uncharacteristically not rushed into a new relationship and was adopting a “wait and see” approach to dating. At termination, the Anxiety Disorders Interview Schedule for DSM-IV indicated a score of 3 out of 8 for panic disorder (subsyndromal), 3 out of 8 for agoraphobia, and a score of 0 for generalized anxiety disorder.
These two small adult studies demonstrate preliminary but promising outcomes of psychotherapies for patients with prominent separation anxiety symptoms amid different DSM disorders. Better tracking of separation anxiety throughout treatment course and the development of interventions to relieve its global effects might help in specifically targeting interventions for individual patients.