Intergenerational Attachment Styles, Emotional Regulation and Relational Outcomes in Couples Therapy

Abstract

This chapter focuses on the theoretical basis behind intergenerational attachment styles and how they present in romantic relationships. In this chapter, we review the conceptual literature on attachment styles, their development and maintenance across the lifespan. We also explore the role of mutual emotional regulation in disrupting relational distress and improving relationship functioning. We proceed to synthesise efficacy studies and evidence-based research on relational interventions with couples, most commonly presenting concerns in couples therapy and the role of couples therapy in improving romantic relationships across cultural contexts, gender and sexuality identifications. We summarise what has worked, with whom and why while reviewing the various measures and types of clinical interventions offered to couples and report on change scores in outcomes of attachment avoidance/anxiety, relational conflict, relationship functioning and partner satisfaction. Finally, the book chapter presents three case studies with South-Asian couples across diverse life stages, relationship statuses, gender identities and sexual orientations using attachment-based and emotion-focused interventions.

1. Introduction

Attachment theory is based on the premise that an infant and caregiver form a bonded relationship. John Bowlby proposed that an infant’s innate behavioural tendencies are driven by a biologically-based, motivational system called attachment [2]. The organisation of the attachment behavioural systems involves the following three components–behavioural, emotional, and cognitive [2, 3, 4]. An infant separated from a caregiver, experiences intense distress and goes to extraordinary lengths-cries, clings and searches for the attachment figure to prevent separation and re-establish proximity. Therefore, the infant’s goal-oriented behavioural tendencies such as seeking proximity with the caregiver are a biologically-driven, motivational system. The intense distress represents the activation of the emotional component of attachment. Separation from a caregiver leads to an intense state of arousal and anxiety, whereas proximity evokes positive emotions. Emotions provide self-regulatory functions in the attachment behavioural system [5]. Finally, attachment behavioural systems include the cognitive component, such as, the infant’s mental representation of the attachment figure, self, and the environment [3, 4]. Ainsworth proposed that the infant also uses the attachment figure as a secure base from which to explore the environment, a critical component of attachment. During the first year of the infant’s life, the infant learns to maintain the delicate balance between attachment and exploration through assessment of the environment and availability of the attachment figure. In times of distress, the attachment behavioural systems are activated and exploration ceases, whereas when the infant is confident of the availability of the attachment figure, playful exploration of the environment increases [6]. Overall, the activation of the attachment behavioural system is evolutionarily designed to enhance the infant’s survival [3, 4].

Research questions

• What is the nature of the relationship between attachment in early years, the formation of attachment styles, and its impact on romantic relationships with partners?

• What is the role played by an individual’s emotional regulation and capacity for mutual regulation with one’s partner?

• What are some of the key evidence-based psychotherapy models that utilise intergenerational attachment and relational techniques in assessment and intervention with couples?

• What is the efficacy for these models- what works, with whom, in what contexts, and why?

• What is the scope for these evidence-based models with South Asian couples and what can we learn from the clinical case studies?

Objectives

• To introduce readers to the continuity and variations in interpersonal attachment from infancy (with caregivers) to adulthood (romantic partners)

• To review attachment styles in adulthood and how they present in romantic relationships

• To highlight key theoretical models relevant to interventions with couples that focus on attachment themes, interpersonal relational style and emotional regulation

• To synthesise literature from various evidence-based models and studies across the globe that offer interventions to distressed couples and note key measurement tools, sample characteristics and relational outcomes in these populations

• To provide clinical evidence of attachment-informed psychotherapy with South-Asian clients

Methodology

We carried out a rapid review of relevant studies focusing on key word searches across google scholar and EBSCO host search engines with search terms that included “attachment”, “intergenerational” “couples therapy” and “relational distress”. Rapid reviews are literature reviews conducted systematically within a limited time frame and with specific databases [1]. We addressed the chapter objectives by drawing insights from two sources: synthesising information from studies matrixed during the literature review and clinical case notes from three therapists who work with couples using intergenerational attachment and relational assessments as well as interventions (MI, MP and SV). The matrix to tabulate studies included variables such as sample demographics, location (country), therapist demographics, key variables, measurements used and key findings. For the clinical case studies, each case was written up in a similar format by each of the therapists’ vis-a-vis: (1) presenting concerns, (2) intergenerational assessment and relational cycle identification, (3) relational-focused and strengths-based interventions and strategies utilised to reduce distress and meet couples’ therapeutic goals. The two sections are presented sequentially in the chapter.

2. Role of Internal Working Models (IWM) and Mutual Regulations Model (MRM) in attachment

Developmentally, attachment serves a survival function in babies; whereby babies rely on a consistent caregiver to meet their needs and protect them from threat or harm. The quality of these early interactions of infants and children with their caregivers shapes their subsequent and later psychological and interpersonal interactions in life [7]. This occurs through the development of the infant’s internal working model; mental representations of the self and others [8, 9]. With a sensitive and responsive caregiver, infants develop a working model of others as available and themselves as worthy of care. With an inconsistent or rejecting caregiver, infants may develop a model of others as unavailable and themselves as unworthy of care. The internal working model serves a predictive purpose to imagine how a caregiver will behave and thus hold expectations or plan one’s own actions in response [10, 11]. According to Bowlby [10], gradually the internal working model (IWM) representations become the property of the child and are carried into adulthood and guide how individuals attend to, interpret, and behave in close relationships [11]. Emotions and emotional communications between an infant and caregiver play a critical role in the evaluative process, shaping the infant’s internal working model as well as defining goals and developmental pathways [5, 12]. Interactional behaviours of the infant, such as, looking away or looking at an object serves a self-directed or other-directed, emotional regulatory biophysiological purpose for the infant [13]. When parents are sensitive to these emotional and behavioural indicators and respond appropriately, the infant successfully attains the goal and experiences a state of positive emotion. On the contrary, when caregivers fail to respond appropriately, the infant fails to meet interactive goals and this evaluative process leads to negative emotions [12].

Tronick’s mutual regulation model [12] revolutionised the understanding of reciprocal and mutually regulated systems of affective coordination in the infant-caregiver dyad [14]. For example, Tronick’s Still Face (S-F) Paradigm [14] experiment, demonstrated the mismatched interactions and its effect on the infant. In this experiment, the infant and caregiver engage with each other (emotionally and physically) and after a period of engagement, the caregiver is asked to present a neutral poker face or the still-faced expression and disengage from any conversation or physical contact with the infant. This period of disengagement is followed by a period of reunion, where the caregiver reengages with the infant. During the period of disengagement, the infant tries diverse affective repairs to engage the still-faced caregiver. The infant’s failure to repair the emotional engagement with the caregiver induces stress, negative emotions (anger, protests, frustration, and sadness) and creates a mismatch [14]. However, in the reunion phase, when the caregiver re-engages and the infant responds with positive emotions, the parent’s regulatory role is established, and the affective mismatch is repaired successfully. However, longer duration of infant-caregiver dyadic mismatch creates developmental pathways for psychopathology and relational distress [14, 15].

In depressed mother-infant dyads, the disengagement and interactions from caregivers limits the infant’s ability to transform negative affect to positive, and is detrimental to the mental health of the infant [12]. Several researchers have tested the MRM model, for instance, Egmose and colleagues [16] conducted a comparative study on mutual regulation through touching behaviours in two sets of dyads (24 postpartum depressed mother-infant dyads, and 47 non-clinical mother-infant dyads). They found that mothers use different touching behaviours to regulate infant’s negative versus positive facial affect and infants respond with negative versus positive affect to different maternal touching behaviours too. Typically, caregiving maternal touch (parent behaviour displayed by adjusting the infant’s seat or wiping their mouth) are used to regulate infants’ negative facial affect whereas playful touch (such as, tickling, jiggling, and large movements with the arms) are used to enhance positive affect. Moreover, infants were more likely to demonstrate positive affect due to a playful maternal touch and decrease in negative affect as a result of caregiving maternal touch [16]. Contrary to previous findings that depressed mothers do not engage with their infants, mothers with postpartum depression, in this study, used affectionate touch (such as, patting, nuzzling, kissing, stroking or caressing) to reduce negative infant facial affect as compared to non-clinical mothers [16].

Consequently, developmental pathways are shaped by the infant’s moment-by-moment meaning-making process in the mutually regulating dyadic relational system. Thereby, increasing the emotional and coping capacities of the infant and creating coherence in the dyadic system through repeated reparations [12, 14, 15]. This also creates diversity and complexity in the infant’s experiences to successfully self-regulate and use the other (the caregiver) as a regulatory mechanism, thereby shaping the infant’s ability to transform negative to positive emotions and influencing their internal working model of relationships [12, 15, 16]. However, repeated failed affective reparations leads to limited exposure to diverse experiences of reparation and lack of coherence in the infant-caregiver dyadic emotional communication [12, 15]. Recent studies have extended the understanding of mutual regulation models. The dynamic interactional intersubjective experience of knowing to be with each other and ways to repair or work things out together results in an implicit procedural knowledge, a mental representation of implicit relational knowing (IRK) [13]. Banella and Tronick [17] found evidence of UIRK in 11-month-olds as compared to 6-month-olds. This developmental change is incorporated in the memory in the form of two types of implicit knowing- relational and procedural understanding of relating. Thus, the dyadic relationship paves the way for unique patterns of relational knowing (UIRK) through mutual co-creation of meaning-making, regulation of affect and interactional understanding from the repetitive interactions and repairs at various times and contexts of daily living. Hence, the co-creation of the mutually coordinated reciprocity, whether coherent, complex or messy, is unique in infant-caregiver relationships and happens in everyday moment-by-moment interactions with the caregiver [17, 18] and becomes a part of the implicit psychobiological memory process [18]. Thereby, the unique implicit relational knowing (UIRK) [17, 18] plays a crucial role in formative relationships and influences how the infant feels about self and others in future relationships [18].

3. Attachment patterns in infancy, adolescence and adulthood

Internal working models and attachment patterns are also subject to intergenerational transmission and parenting responses [19]. In infant-parent relationships, they guide a parent’s behaviour towards the infant, and, as a result, influence the infant’s own developing internal working model [20, 21, 22, 23]. A parent with a secure and consistent internal working model is more likely to interpret their infant’s attachment signals appropriately, whereas a parent with an insecure internal working model is less likely to do so [24, 25, 26, 27]. Research has demonstrated that mothers with unresolved trauma tend to have infants who display profoundly disorganised attachment [28, 29, 30]. A meta-analysis reviewing 661 mother-infant dyads found a 75% match of secure/insecure attachment classifications [31]. Similarly, findings from another study of grandmother-mother–child dyads suggested continuity of attachment patterns across three generations [32]. Thus, these attachment behaviours and dyadic interactions with caregivers develop into more enduring, permanent attachment styles in adulthood.

Ainsworth and colleagues [33] studied individual differences in attachment patterns and initially distinguished between three types of attachment in infancy: secure, anxious, and avoidant, based on the strange situation study of infant-mother interactions. Securely attached infants became upset when the mother left the room and when she returned, they actively sought their mothers and were easily comforted by them. For those infants indicating anxious attachment, they became distressed upon separation and had a difficult time being soothed during reunion. They possibly experienced uncertainty about love from their attachment figure. For infants demonstrating avoidant attachment, they appeared to be mildly distressed during separation and actively avoided their mothers upon reunion, appearing self-reliant. In later years, Main and Solomon [34, 35] added the disorganised attachment style, referring to children who have no predictable pattern of attachment behaviours. They viewed their caregiver as a source of both comfort and fear, leading to conflicting behaviours. Attachment models developed in infancy are carried throughout later years as models of connection and disconnection. They can be transferred into adult relationships [36, 37] and directly influence the quality of peer relations [38]. In teenagers and young adults, secure attachment, that takes the shape of emotional availability from caregivers, helps to form a developing worldview, build a sense of self and determines peer interactions and MH (mental health) outcomes [39]. Additionally, adolescents with secure attachment reported ease in seeking and providing support as well as finding a space among peers where they felt safe. They’re able to integrate their past attachment experiences favourably and present a more developed concept of friendship. Greater insecurity to parents and peers in adolescence predicted a more anxious romantic attachment style and greater use of emotion-oriented strategies in adulthood. Avoidant attachment style was related to less support-seeking and greater isolation and the presentation of mental health concerns like depression in adult life [40]. Adolescents with ambivalent attachment struggle with managing conflict and experience intense reactions in their close relationships. Adolescents with avoidant attachment tend to avoid emotional engagement, demonstrated through coldness or distance with peers, have more interpersonal conflict and hold low expectations of what friendships mean [41, 42].

Moreover, attachment in infant-caregiver and partner relationships are unique and significantly impact the physical and psychological wellbeing of the dyads. Attachment in partner relationships is also defined as pair-bond attachments and can be compared with infant-caregiver relationship as both trigger the same hormonal and neurophysiological mechanism [43, 44]. Bartholomew and Horowitz [45] categorised adult attachment into four styles emerging from two underlying dimensions: anxiety (indicated by the extent to which individuals worry about abandonment and rejection; and avoidance (concerning the extent to which individuals limit intimacy with others). The four attachment styles are secure, preoccupied, dismissive-avoidant and fearful-avoidant. Secure attachment is characterised by low anxiety and low avoidance. Individuals have a positive model of the self as worthy of love and others as generally accepting and responsive. A preoccupied attachment style is characterised by high anxiety and low avoidance. These individuals harbour a negative model of the self as unworthy of love and thus worry about losing their partners and remain vigilant to signs their partners might be pulling away from them. To prevent this, they tend to use hyperactivating strategies to get closer to their partners to feel secure. They desire to merge with the other, expect partners to fill their needs and may be threatened by their partner’s autonomy, leading to resentment and disappointment. A dismissing-avoidant style is characterised by low anxiety and high avoidance, manifesting as discomfort with intimacy and closeness in relationships. Individuals may hold a negative evaluation of others as clingy, needy and dependent. They strive to create and maintain independence, control and autonomy in their relationships because they may believe that to seek proximity is not possible or undesirable. Finally, a fearful-avoidant attachment style is characterised by both high anxiety and avoidance. These individuals desire closeness with others but fear rejection. They maintain a distance as a means to protect themselves. These four attachment styles provide a window into the way individuals relate to those close to them [45].

4. Attachment patterns in adult romantic relationships

Attachment patterns are also used to negotiate interactions with romantic partners. Hazan and Shaver [46] observed a number of parallels between infant-parent attachments and romantic relationships, including a desire to be in physical proximity to the other; seeking the other when distressed, scared or ill; and using the other as a secure base from which to explore the world. In their study, secure adults described their romantic relationships as happy, friendly, and trusting, emphasised their ability to support and accept their partner despite their faults, and had relationships that tended to last longer than both individuals with insecure attachments. More recently, attachment styles are often represented in a two-dimensional space defined by attachment avoidance and attachment anxiety [21, 45]. Bartholomew and Horowitz [45] categorised adult attachment into four styles emerging from two underlying dimensions: anxiety (indicated by the extent to which individuals worry about abandonment and rejection; and avoidance (concerning the extent to which individuals limit intimacy with others). The four attachment styles are secure, preoccupied, dismissive-avoidant and fearful-avoidant. Secure attachment is characterised by low anxiety and low avoidance. Individuals have a positive model of the self as worthy of love and others as generally accepting and responsive. A preoccupied attachment style is characterised by high anxiety and low avoidance. These individuals harbour a negative model of the self as unworthy of love and thus worry about losing their partners and remain vigilant to signs their partners might be pulling away from them. Such individuals tend to be preoccupied with issues surrounding their partner’s predictability, dependability and trustworthiness [47, 48]. They tend to question their worth, worry about losing their partner and remain vigilant to signs their partner might be pulling away from them. The relationship becomes a significant focus of their lives, on which they place unrealistically high expectations [49]. They may be threatened by their partner’s autonomy, leading to resentment and ambivalence. To prevent this, they tend to use hyperactivating strategies to get closer to their partners to feel secure. They desire to merge with the other, expect partners to fill their needs and may be threatened by their partner’s autonomy, leading to resentment and disappointment. A dismissing-avoidant style is characterised by low anxiety and high avoidance, manifesting as discomfort with intimacy and closeness in relationships. These individuals may hold a negative evaluation of others as clingy, needy and dependent. They strive to create and maintain independence, control and autonomy in their relationships because they may believe that to seek proximity is not possible or undesirable. Individuals expressing avoidant attachment tend to be pre-eminently concerned about avoiding excessive intimacy and commitment in relationships. They find it difficult to trust others and prefer to maintain an emotional distance. In their romantic relationships they may be mistrustful and think of the relationship as emotionally demanding. They strive to create and maintain independence, control and autonomy in their relationships and evaluate their partners as needy, clingy or dependent. Avoidant partners use de-activating strategies to downplay attachment-related threats and deny attachment needs. They become defensive, underestimate the negativity of partners’ messages, engage in physical and emotional withdrawal and reduce expressions of support; these behaviours often frustrate partners [50]. Finally, a fearful-avoidant attachment style is characterised by both high anxiety and avoidance. These individuals desire closeness with others but fear rejection. They maintain a distance as a means to protect themselves. These individuals are found to be more hostile and distressed during conflict-discussions, and perceive their relationships more negatively afterwards. They tend to respond to conflict with physiological arousal and hyperactivating behaviours, designed to force partners to provide more attention and support. This egocentric stance involves neglecting a partner’s needs and engaging in blame and coercion. These tactics often alienate partners, creating ongoing distress. These four attachment styles provide a window into the way most individuals relate to those close to them [45].

The different insecure attachment styles are related to less positive romantic relationships in adulthood. The relationships are characterised by less interdependence, trust, commitment and satisfaction, as well as greater relational jealousy and perceived intrusiveness from the romantic partner [51, 52]. Both an anxious and avoidant attachment style are considered risk factors for the expression of aggression towards one’s partner [53]. A meta-analysis of anxious and avoidant attachment styles in romantic relationships indicated that both styles have detrimental effects on physical, emotional, cognitive and behavioural aspects of romantic relationships, with attachment avoidance being more detrimental to relationship satisfaction, connectedness and support while attachment anxiousness was associated with greater relational conflicts [47, 54]. Furthermore, preoccupied, dismissive-avoidant and fearful-avoidant attachment styles when present in both partners lead to high levels of romantic disengagement [55, 56]. Conversely, secure attachments are stated to be at the core of close, fulfilling relationships. These secure relationships provide individuals with a safe haven and secure base during threatening or distressful situations [5, 57, 58]. These relationships are also characterised by greater longevity, trust, commitment, and interdependence [59, 60]. Kobak and Hazan [61] observed that secure partners engaged in more constructive problem-solving interactions than insecure partners and found significant associations between attachment security and marital satisfaction.

5. Theoretical frameworks

5.1 Interpersonal theories

Drawing on interpersonal theories of personality, Bartholomew [62] noted that individuals tend to select social partners who sustain their initial dispositions (i.e., working models). Avoidant adults may choose ambivalent partners whose dependence confirms their expectations of relationships. Similarly, an ambivalent person faced with an avoidant partner receives confirmation of their working model of relationships in which others are reluctant to get close and unwilling to commit to a relationship. So, in a way, each attachment style is drawn to re-enact a familiar script over and over again [63, 64]. Secure adults are less likely to select partners who either avoid or are preoccupied with intimacy. They would opt for secure partners who share and confirm their comfort in close relationships [65, 66]. Attachment styles may be an important dimension by which individuals choose their marital partners.

5.2 Social learning theory

Social learning theories suggest that communication and conflict resolution strategies individuals bring into the relationship are learned in the family-of-origin [67, 68]. Consistent with this theory, studies have found that family-of-origin problems were associated with poorer communication skills, expression of negative affect, lack of openness, greater avoidance behaviours and less willingness to negotiate [69, 70]. Additionally, attachment behaviours (accessibility, responsiveness, and engagement) significantly mediated the relationship between family-of-origin problems and communication skills. Wampler et al. [69] found that individuals who reported lack of attachment security intergenerationally are more likely to express negative affect, lack of openness, more avoidance and, less willingness to negotiate with their partner. Studies have also focused on the quality of the participants’ parents’ relationship with each other, and when individuals perceived poor marital relations in the family of-origin, it negatively affected their attributions about their partner’s communication and perceived emotional connection [71, 72].

5.3 Attachment theory

More broadly, attachment theory is recognised as one of the most important frameworks for understanding romantic relationships [73] and its formation and success [70]. Insecurely attached partners encounter fears of closeness, feelings of jealousy, attitudes of distrust and heightened overall relational distress [74]. When presenting in couples therapy, they often raise behavioural and emotional concerns around not being prioritised enough or being ignored by their partner, feeling overwhelmed by partners’ feelings, experiencing financial and logistical difficulties or difficulties navigating relationships outside of the couple unit like parents, children and so on [75, 76]. When individuals begin to distrust their partner’s accessibility, responsiveness and engagement, they withdraw from each other. This weakens the relationship, further exacerbating the partners’ fears and anxieties and worsening their mental health [77, 78, 79]. Oftentimes, these concerns manifest as relational mistrust, lack of quality time spent together, high levels of conflict, blaming or withdrawal from one partner and a host of other poor adaptations or outcomes. This leaves individuals more vulnerable and exposed to stress and developing mental health concerns [80] including generalised anxiety, depression and symptoms of psychosis [81, 82, 83, 84].

Numerous studies have found strong empirical support for differences in relationship satisfaction, psychological well-being (e.g., self-esteem, depression) and childhood experiences as a function of secure, avoidant, and ambivalent attachment styles in adulthood [45, 85, 86]. While longitudinal studies have provided the strongest evidence for the continuity of attachment styles from childhood to adulthood [87, 88, 89], other research studies have shown that attachments are subject to change based on new experiences and relationship environments [21, 45, 60, 90]. This provides an opportunity for intervention research to explore and evaluate how relational, attachment-focused interventions might serve as mechanisms of positive change for insecure attachment styles. Studies have shown that clinical interventions can be effective in shifting people’s attachment anxiety and avoidance. For example, asking people to reflect on fostering security in their relationships and/or experiences appears to cause them to behave more securely. They’re able to exhibit greater empathetic, creative and responsive behaviours [91, 92, 93, 94, 95]. Interventions that are repeatedly administered, may be able to change people’s enduring trait level anxiety and avoidance, with effects on relationship functioning and wellbeing [96, 97]. Furthermore, looking at how family-of-origin experiences spill out into interactional patterns with one’s spouse may be one way to improve marital communication. This provides an optimistic view of relationships for those who have experienced negative family-of-origin experiences including high family conflict, violence, hostility and parental divorce [70].

Therefore, models and therapies with a relational focus- which emphasises holding awareness of the self, other and the relationship, might be one approach to help re-engage couples, reaffirm affection between romantic partners as well as ultimately help sustain intimacy and satisfaction [56]. Furthermore, when the emotions and motivations of romantic partners are framed as their expressed need, there is a greater scope to look at problematic interactional cycles and find scope for change through new experiences [98, 99]. The skills learned in therapy including positive communication and healthy conflict resolution are also strongly associated with greater marital satisfaction [99].

6. Efficacy studies from intervention models

To better understand the mechanisms of adult attachment, various empirically supported treatments for couples have been developed and tested in the last few decades [100, 101, 102, 103, 104, 105]. The most prominent evidence base is for attachment-focused and communication enhancing models including emotionally focused couples therapy (EFcT), integrative behavioural couples therapy (IBCT) and the Gottman method. These models view presenting problems as symptoms of struggles with interpersonal effectiveness and communication, as a result of insecure attachments.

Several different therapeutic modalities have been measured against one another to assess the impact on relational outcomes. Byrne et al. [106] studied the efficacy of behavioural couples therapy and emotionally focused couples therapy with distressed couples. Across 20 studies (13 IBCT and 7 EFcT), they found that IBCT fares better than 83% and EFcT 89% of untreated couples and these gains were maintained at a 2-year follow up. Ahmadi et al. [107] and Havaasi et al. [105] found that EFcT and Gottman couple therapy methods reduced marital burnout and changed conflict resolution styles (P < 0.05), with EFcT being more effective. In EFcT specifically, increasing awareness of primary and secondary emotions and encouraging the partner who typically takes a blaming/critical stance to express their attachment needs and fears (blamer-softening), were responsible for facilitating further decreases in couples’ attachment insecurity and relationship distress [108, 109]. This change occurs through an increase in both partners’ level of engagement during therapy, especially those who are classified with avoidant attachment styles, especially men who have higher disengagement scores especially when paired with anxiously attached partners [56]. Especially men higher on attachment avoidance reported greater romantic disengagement at follow-up. Moser et al. [110] found that there were measured decreases in attachment avoidance and attachment anxiety (following blamer softening sessions) and an overall increase in relational satisfaction upon completion of EFcT. Therefore, changes in relationship-specific attachment anxiety, secure attachment behaviours and relationship functioning may be long-lasting and continue to improve in the years following therapy for those couples who engaged in and completed EFcT [104].

The most common measures used to gather data on attachment styles are the Experience in Close Relationships (ECR), the Adult Attachment Scale (AAS), the Adult Attachment Interview (AAI) and the Brief Accessibility Responsiveness and Engagement Scale (BARE). While these measures attempt to record the same aspects of functioning in close relationships, they predict outcomes captured at different developmental stages resulting in low convergence between measures [21].Other relational and functional measures across studies have been checking relationship satisfaction via the Dyadic Adjustment Scale (DAS), the Relate Scale of Family Quality and Family Communication, Pine’s measure for Burnout, Rahim Organizational Conflict Inventory (ROCI) for conflict resolution, Romantic Disengagement Scale (RDS), the relational Q-sort, The Secure Base Scoring System (SBSS) and Difficulties in Emotional Regulation Scale (DERS) for emotional regulation.

Across studies, EFcT, which focuses on improving attachment styles and de-escalating conflict, has been seen as an effective intervention for all of the above outcomes. Specifically, EFcT has been found across studies to improve relationship satisfaction between partners and increase attunement and responsive behaviours, characteristic of secure attachment and reduced attachment anxiety and/or avoidance between partners [111, 112]. Benson et al. [113] concluded that changes in attachment style (especially attachment anxiety) and marital satisfaction work concurrently over the course of therapy. EFcT has also been found effective for a number of populations expressing a variety of concerns including cancer care [114], PTSD [115], depression in one of the romantic partners [116], spousal abuse [117] and infertility [118]. EFcT and Gottman have also been tested cross-culturally with promising findings in Iran, Ireland, Israel, Taiwan and Thailand [72, 107, 119, 120, 121]. However, there are drawbacks to these findings. A significant limitation is that a majority of these studies are tested in North America and by teams led by or advised by the model developers which leads to allegiance effects and lack of cultural transferability [119]. In terms of participants, most studies have also been conducted with heterosexual, married couples in their middle age (late 30s to mid-40s). Additionally, in several studies, the therapists training and identities have not been considered as a co-variant factor and data has been collected by largely using self-report measures. In our contribution, we aim to expand the research on attachment by providing more experiential narratives through therapeutic case vignettes across age groups, genders and sexuality orientations.

7. Case studies

We have used Benson et al.’s framework [122] while looking into the cases. He proposed that there are five common evidence-based factors or principles to guide interventions with couples experiencing relationship distress. They are: (1) altering the couple’s view of the presenting problem to be more objective, adult-focused problems, (2) decreasing emotion-driven, dysfunctional behaviour; (3) eliciting emotion-based, avoided, private behaviour; (4) increasing constructive communication patterns; and (5) promoting strengths and reinforcing gains.

7.1 Case study 1

Ali and Samara are a young couple in their late 20s. Ali works in the Indian armed forces and is posted in a different location every few years while Samara lives in the national capital of India- New Delhi. They have known each other since high school and began their relationship as friends. Ali had been in love with Samara for years but they only began dating one another in 2019 and subsequently got married in 2021. They presented to therapy raising concerns of a lack of adjustment to each other’s needs post marriage, divergent opinions in decision making, feeling dissatisfied in their relationship and feeling unsure about their future together.

7.1.1 Initial sessions and assessment

A total of 14 sessions were conducted with the therapist (MI, first author). The first few sessions involved a systemic assessment of their relationship history, identifying other key stakeholders (parents, siblings and friends) as well as more recent contextual issues (arguments about relationships with respective families-of-origin, Samara’s recent abortion, individual career plans, finances and heightened emotional interactions during conflicts). The plan for attachment-oriented emotionally focused couples therapy as a treatment format was shared after discussing hopes for their relationship and setting goals in therapy. As per EFcT, a few sessions explored their cycle of conflict and increasing awareness to help de-escalate future conflict. Next, attachment styles were explored. This was obtained through individual sessions with each partner where an attachment narrative was drawn, their understanding around their attachment styles and resultant emotions were deepened. Finally, partners were brought back together for joint sessions to address injuries in their attachment, increase their sense of longing for support and cohesion along with deliberating on possible goals for the future.

7.1.2 Relational conflict cycle

The relational conflicts for Samara and Ali seemed to originate with them wanting to plan out certain crucial life priorities. For Samara, this included immediately being in an independent home of their own where Ali could visit and spend time when he was not at a posting in the armed forces. For Ali, this included buying a car and financial planning for a future home. Furthermore, individual needs also came to the fore. Samara wished to pursue higher studies in a doctorate abroad and Ali expressed exhaustion around his current posting and wished for further training and self-development between his postings. This would often lead to issues about whose needs to prioritise, lack of time for each other and continuing disagreements. Samara would get agitated and display heightened emotions, that caused Ali to shut down. Repetitive pleas from Samara to solve their conflicts led to Ali withdrawing further or having anger outbursts that traumatised Samara and reminded her of how she felt in her own family. Ali would feel embarrassed by his behaviour and withdraw from her or distract himself instead of connecting with her when she was in this hurt state.

7.1.3 Intergenerational attachment history of both partners

Samara- In individual sessions, her relationships within her family-of-origin were explored. It came to light that Samara had taken on the role of a caretaker for her mother and felt parentified because her mother struggles with chronic physical and mental health issues, including diabetes and bipolar disorder. As a result, she had not felt like she could lean on her mother or rely on her to meet her emotional needs. Samara’s father also worked in the armed forces and would spend a lot of time away from the family. When he was home, he was also a stickler for discipline, schedule and financial control. Samara often felt that she did not get enough pocket money or allowances from her parents. As a result, she began to do part-time jobs at the age of 16. This perceived lack of importance or having low value to her parents may have resulted in Samara’s anxious-preoccupied attachment style, and is reflected in her relationship with Ali, especially given their long-distance relationship. In individual sessions, MI deepened her emotions around her anxieties for finances, which also manifested in her relationship with Ali, when he would not send her the house rental allowance payments on time or wanted to buy a car that was beyond their means. In her attachment style with Ali, she identified how she would make demands or pleas for her emotions to be validated during difficult times (i.e., the abortion or when there was forcefulness from his parents about having a baby) and for her needs to be met but when disregarded she became blaming, hopeless and disengaged, feeling like he did not care for her or that she was of no value to him.

Ali- In individual sessions with Ali, an exploration of his intergenerational attachment history revealed that he did not feel close to either of his parents and had no other significant caregivers that he relied on during his early years. Ali changed homes and schools frequently due to his father’s job and was physically punished at home and in school for low academic performance. He faced adjustment issues and was bullied by his peers due to his accent, physical appearance and shy personality. On one occasion, he was described to have been bullied badly by his peers and was held accountable for something he did not do. He lost his sense of trust and reliance on his parents being there for him. The parents followed the advice of his school principal and he was suspended for a few weeks. The topic was never discussed in his family and Ali felt he had been punished and made invisible. The above factors may have laid the foundation for his tendency to withdraw from others and his avoidant attachment style.

Through individual sessions, MI deepened his emotions and experiences around being bullied, feeling like an outcast and his subsequent mental health concerns. He discussed that his mental health concerns of depression and lack of focus and concentration on academic goals became a source of great embarrassment in his family and till date, he withholds sharing his struggles in the armed forces with his parents and Samara. He attempts to protect Samara from his parent’s style of relating to the couple which includes high expectations, low levels of attunement and an environment of subservience to their advice. As a result, Samara feels tentative around his family and that he is constantly hiding things from her. His difficulty with opening up to her emotionally also exacerbates her insecurities about herself and increases her demands for attention, validation and care.

7.1.4 Interventions based on attachment needs

Bringing them back together in joint sessions was important but metaphorically also helped them turn towards each other to address attachment wounds and explore the significant ruptures in their relationship, instead of turning away and feeling isolated.

7.1.5 Softening the anxious partner

T: So, Samara, you had brought up how hurt you felt by Ali when you could not talk about the abortion and the argument you both had about his parents’ reaction that you should have the baby. This was a major moment of pain for you. Can you share this with Ali and give him a chance to understand better this time around?

S: I basically felt that he deferred to them when they were trying to make a decision about my body. It was dehumanising and it felt like I was on my own in the world, the same way I felt when I was younger.

A: I am truly sorry for making you feel that way. It was a moment of panic for me too but I should have not shut down and instead been there for you, for us. I often get intimidated by my parents and fear disappointing them- with my academics, my career, my personal choices. It’s something I need to work on.

7.1.6 Re-engaging the avoidant partner

T: Ali, we spoke about your experiences of being bullied and how that impacted your well-being and functioning. It sounds like this happens to you when Samara is upset and blames you. In these situations, you feel that she, just like your parents, are not on your side and that you are being attacked or picked on. Can you share more on this with her?

A: Yes. I feel that Samara is also trying to embarrass me or put me down. I tend to feel like everything is my fault or that I am the failure and I shut you out with silent treatment. I pull away from you (use of distancing strategies).

T: What do you need from Samara during these times?

A: To make space for my feelings and to notice that I am holding back to avoid more fights with her, that I want peace with her.

T: Samara, did you know that Ali tries to pull away so you fight less?

S: I guess I had realised that it was his way of diffusing the situation but I am only now realising it comes at a cost to him.

T: How does this feel for you Samara, when Ali pulls away?

S: I feel like I have been abandoned by him and I mean nothing to him (low self-worth emerges). I get scared that he will leave me.

T: Ali, were you aware of how your actions impacted her emotionally and that she is scared to lose you? (Creating space for longing and re-connection).

A: I did not and would not ever want her to feel that way. I was simply trying to keep her away from my own confusions about my career so she would not get concerned about our future.

7.1.7 Designing and building a future together

Towards the end of therapy, goals were discussed in a mutual and reciprocal way. They included dividing finances, supporting each other to achieve individual milestones and plan career trajectories and drawing healthy boundaries between themselves and others, especially the involvement of his parents in decisions like child-bearing, investments, etc. Ali shared with Samara that he did not see himself working in the armed forces in the longer-term. He would like to quit in the next few years to explore a career associated with his true passion, golf. We also discussed how that would potentially help them chart out a path which considered both partners wishes. We also spoke about how Ali could be flexible in his posting based on where Samara would pursue her PhD, and reduce the number of years continuing a long-distance relationship. They ended therapy with the motivation to be more attuned to each other, have empathy for their respective attachment styles and to further the skills they acquired during therapy to communicate more cohesively.

7.2 Case study 2

Priya and Raman are in their mid-40s. They have been in a relationship for 20 years and married for 15 years. Priya wants to seek couples therapy as she and Raman have become distant from each other and their marriage lacks intimacy. They hardly share their feelings with each other, and when they do it escalates into a major conflict with Raman distancing himself and Priya feeling overwhelmed and hurt in the relationship. For Priya, if their present status quo is maintained, she can no longer see herself in a marriage with Raman. Although Raman did not want counselling, he agreed to try couples therapy on Priya’s insistence. He understands that if he does not participate, Priya will file for divorce. He does not want to start over again in life at this age and they have a daughter to think about. Therefore, he has agreed to therapy. Both agreed that their relationship has reached a level of stagnancy after years of being together. They both identified issues of trust, intimacy and stagnancy in their relationship.

7.2.1 Relational conflict cycle

A total of 24 sessions were conducted with the therapist (MP, second author). Initial sessions with the couple revealed that the major conflict in their marital relationship was the pattern of distancing and closeness, lack of trust and not feeling valued in the relationship. Raman prefers to maintain his emotional independence and does not like sharing, and he finds Priya very clingy and intrusive. Individual sessions with Priya revealed her challenges in her marital relationship.

Priya: According to Priya, they had a greater degree of physical, emotional and intellectual closeness in the first few years of their life together. Though Raman was the one who wanted to be romantically involved with her, she was the one who proposed marriage after a few years of dating him. She shared that he got married because of her insistence on marriage. They enjoyed each other’s company, the intellectual conversations, wit and passion. They identified themselves as a modern, liberal and egalitarian couple. Neither wanted kids at that point. However, 6 years into their relationship, Priya spoke about her desire to be a mother. They had a daughter 6 years into their marriage. Both were working professionals with demanding jobs. Priya ended up making a lot of sacrifices at her workplace to raise their daughter, as Raman would travel a lot. She had to become involved and sometimes it seemed that she was giving too much in the relationship as a parent and partner and did not feel valued. Though she perceived her sexual relationship as good, what she missed was emotional closeness and physical demonstration of love and intimacy such as holding hands, hugging and sharing feelings and thoughts with her. Sometimes, she did not understand what went on in Raman’s mind; he does not disclose. Raman is social, approachable, amicable, witty, attractive, friendly, and has an intellectual command over many subjects but he is very private about his own feelings and avoids personal disclosure. Both have many friends from the same and opposite sex and it previously never bothered them. However, Priya feels that his female friends behave inappropriately with him, such as clinging to him or caressing his arms and he does not stop them. Such displays of intimacy aren’t shared with her and he also does not express pleasure when she initiates such displays of intimacy. She struggles with trust and level of intimacy in their relationship.

Raman: According to Raman, they were happy for a while and then Priya insisted on having a child and Raman conceded. He found Priya to be too demanding and he did not want to upset their relationship. He also loved her; however, he never asked or expected her to make sacrifices in her career. They were both working professionals and had child care at home and also received support from their in-laws. Though Raman was a hands-on father and as parents they worked well together, in parenting their daughter, Priya took most of the decisions about their daughter. Raman loves his daughter dearly and they get along well. According to him, both spend quality time with their daughter. If one of them is travelling, the other takes care of their daughter. Raman too expressed problems with intimacy. He found it challenging to express love as a married couple after being in a relationship for such a long time. It seems childish to hold hands, hug each other like in Bollywood or Hollywood movies. They both socialise a lot, and have common friends. He mentioned that Priya is possessive and there are trust issues in their relationship along with intimacy. Raman mentioned that if they are at a party, and any of their female friends pull him onto the dance floor or rub his shoulder, Priya gets upset. He shared that he does not show fondness, attention or initiative with another woman. On his part, he finds it rude to stop some women when they request him for a dance or hug him. After all, these are their common friends. According to him, he has been faithful to Priya and has not had any relationship outside his marriage. He described not having any intention to jeopardise his relationship. However, Priya lacks trust in their relationship.

7.2.2 Intergenerational attachment history of both partners

A genogram provided an intergenerational narrative of the family relationship history and the narratives of closeness and distance in the couple’s relationship. Priya’s parents had a conventional marriage. Her mother was warm and loving and her father was the stern disciplinarian and the head of the family. She tried to live up to the expectations of her parents, especially her father. She seeks his validation, respect and appreciation. However, they also have different perspectives, opinions, choices, and disagree very often with each other. Her father shuts down when they argue, and this behaviour irritates her. Therefore, at times she wants closeness with her father, and sometimes, she does not. She is more emotionally invested in her relationship with her father; however, he does not understand, appreciate or reciprocate as per her expectations. She reported a similar pattern of communication and relationship narratives with Raman.

Raman, on the other hand, had a different intergenerational narrative. His parents were very reserved and quiet. His parents barely argued with each other and never raised their voice to express their displeasure. They valued composure, calmness, and intellectual pursuits. Some physical demonstrations of love were shown by his mother; however, his father maintained a very strict demeanour. Raman remembered himself as a rebellious child, getting into conflicts with his father. However, his father never raised his voice even when he expressed his displeasures. His family pursued intelligent discussions rather than emotional and physical displays of love during family time. Raman shared that as a child he may have wanted his parents’ validation or appreciation but he let go of these expectations a long time ago. He does not express or share his feelings with Priya and others, similar to how his family behaved.

The mismatch in the communication emerged from for both Priya and Raman’s narrative. Priya’s revelation shows that she has anxious attachment, whereas Raman displays avoidant attachment in their relationship history. Finally, an assessment of the patterns of conflict in the couple’s relationship revealed that Raman withdraws from intimacy, whereas Priya pursues physical and emotional intimacy. They repeat the distance-pursuer patterns of communication where the wife demands and the husband withdraws from connection in their relationship.

7.2.3 Interventions based on Gottman Method Couple Therapy

The Gottman Method Couple Therapy guides the therapist to focus on the initial conjoint and individual session to understand the positives and the negatives in the relationship and the shared meaning making process in the couple relationship. In addition, the individual sessions provide an understanding of the individual partner’s history of relationship with the parents and the parental relationship [123]. The therapist also works with the couple to identify the patterns of conflict (such as the four horsemen-criticism, contempt, withdrawal and stonewalling). Interventions are designed to help the couple down-regulate negative affect, up-regulate positive affect and develop shared meaning making. Furthermore, focusing on improving the positive to negative interactions provides stability to the couple relationship [123].

7.2.4 Focusing on the positives

Both Raman and Priya agreed that intimacy has been a major conflict in their relationship and trust issues stemmed from lack of fulfilment in their relationship. However, both were able to identify certain strengths in their relationships. Both identified each other as important in their life. They agreed that they have maintained respect towards each other, even in their anger. They are not physically or verbally abusive towards each other unlike other couples in their peer group. Priya still finds Raman charming and witty and for Raman, he described Priya to be a very talented and artistic individual. They also respect each other’s individuality unlike their own families. Therefore, the couple values each other as individuals in their relationship.

7.2.5 Focusing on the negatives

The therapy sessions also involved the couple identifying the disruptive patterns of communication and the associated meaning for each partner. When Priya approaches Raman for connection, whether through physical or emotional intimacy and he withdraws, she experiences hurt. She does not feel appreciated, and when he does not stop their common friend from hugging him or rubbing her hand on his face or arms, Priya feels a deep sense of rejection, jealousy, and distrust. For Priya, physical demonstration of love, such as giving her hugs, holding her hands, touching her hair and cheeks or accepting her non-sexual touch are means of staying connected and feeling secure in their relationship. For her, enjoying emotional closeness and disclosure meant that she valued and appreciated Raman. Conversely, Raman’s disengagement is perceived as insulting and she feels defensive. Raman, on the other hand, viewed that as a middle-aged couple, they did not need physical demonstration of love. He did not learn to value them or express his appreciation or love to his partner in such a manner. It also helps him limit his expectations and prevents him from being vulnerable. He discussed feeling vulnerable and less secure about expressing love. It is easy for him not to expect and prefers to be independent. It minimises hurt, expectations and vulnerability. However, when Priya insists, he feels attacked and becomes defensive and withdraws from her.

7.2.6 Focusing on the shared meaning-making

The therapist facilitated the meaning-making and assisted in identifying the negative and dysfunctional patterns of communication and connection. In addition, the therapist also helped the couple assess the level of positive to negative interactions in their relationships and helped each partner listen to the other’s narratives. The couple practised ‘I statements’ in expressing their feelings safely in-session, while the other partner listened. The couple was given homework assignments to practice healthy communication. Multiple ways of sharing were discussed, while Priya preferred verbal discussion, Raman preferred writing small notes. Examining and exploring each partner’s love languages, and strengthening their positive interactions through these love languages helped the couple. Gradually, resolving the couple’s conflicts included working on assignments such as listening to each other, processing each other’s gripe, discussing a repair checklist and collaboratively working on a complaint] together. Raman and Priya worked on repairing their relationship by improving their communication (physical, verbal and written expression of appreciation and closeness). As a couple, Raman and Priya also came up with a shared symbol that would indicate to the other that the partner is feeling overwhelmed, devalued or hurt. This shared symbol allowed Priya to express without feeling overwhelmed, and Raman to request for space without feeling pushed. Towards the end of therapy, the couple felt confident and secure in expressing their closeness, however, they agreed that this would be a work in progress and they will continue to use the tools learnt in therapy for improving their relationship.

7.3 Case study 3

Prana and Chhavi had been in a relationship for 2 years when they came to therapy (with therapist SV, chapter contributor). Both are AFAB (Assigned Female At Birth). Prana uses she/they pronouns and Chhavi uses she/her pronouns. The therapeutic contact lasted for around 6 months. Prana works in the restaurant management space and Chhavi works in social media marketing and with ad agencies. Prana is in their late 30s and Chhavi is in their early 30s. They met in the queer space and had both just stepped out from other relationships. The two-year relationship involved feeling very connected at the beginning of the relationship, finding a lot of relief and camaraderie in each other and things moving quite fast. One year into the relationship, they started living together. However, with time, cracks started to appear. Prana had grown up with a lot of neglect in the family. She also felt a lack of closure and abandonment in previous relationships. Chhavi has always been a high achiever and lives with ADHD. She experiences high energy bursts and wants to try a lot of things. She has felt like she had to do a lot to earn basic praise from her parents. She has had partners who have sometimes been distant, while other partners have been too close and suffocating.

7.3.1 Relational conflict cycle

The presenting concern they came with was that they were having a lot of fights, and also that Chhavi wanted to try an open relationship format where she could see other people while Prana was still the primary partner. They had been to a therapist before and because the fights about open relationships and polyamory were not going anywhere, the previous therapist had asked to pause the conversation on that topic. That had improved things in the short-term. They stopped fighting and saw a slight improvement in their intimacy and communication. However, off late, the discomforts and fights started again, which they wanted to address, and also, they wanted to be able to discuss polyamory in a useful way. The therapist’s understanding about this was that while polyamory may be the presenting issue, it feels like it’s a metaphor for other aspects that both of them feel, abandonment vs. suffocation, and that has in some way or the other, come up in the fights.

Chhavi seemed to want more from intimate spaces, this included seeing other people but also more from Prana. This included more emotional attunement, more praise, more warmth, and in all, a lot of verbal validation. Prana on the other hand, was seeing this as betrayal and abandonment because of past experiences – neglect at the hand of parents and breakups that did not have adequate closure.

Both of them were already facing the brunt of stigma as an invisible couple in many spaces. Their parents and cis-het friends often saw them as friends and not as a couple. They were told not to tell their grandparents due to it being ‘too much’ and would harm the health of the older people. While Prana was out at their workplace to colleagues, Chhavi had to navigate masking her gender identity at work and home too.

The therapist used the Sue Johnson model of negative cycles to conceptualise as well as to explain to the couple, how their defences were feeding off each other. The more Prana became rigid and distant, like a punishing parent, the more Chhavi felt like having multiple partners would meet her needs. However, Prana felt that polyamory would put a lot of pressure on their relationship, be a test of trust and Prana feared that Chhavi may fall out of love. When Prana held too tight due to previous abandonment experiences, Chhavi felt more and more suffocated and started to withdraw in behaviour while withholding communication with Prana. She felt alienated as her emotional and physical needs were not being heard or met. Prana continued to disallow any changes in their relationship and then became deeply wounded every time Chhavi brought up polyamory in therapy.

7.3.2 Intergenerational attachment history of both partners

Chhavi seemed to hold an avoidant attachment style and Prana had an anxious attachment style. Prana tended to over-explain not wanting an open relationship, got really worried about losing the relationship, found it hard to focus at work and was not able to set boundaries for each partner’s personal space. Chhavi, on the other hand, tended to get into alternating cycles of frustration followed by withdrawal by getting distant whenever they had a major fight or there was an expression of Prana’s imagined hurt and distrust.

7.3.3 Interventions based on attachment needs

In the first few sessions, we worked on the idea of balancing adventure with domesticity (the need for safety vs. adventure as posited by Esther Perel) and they decided that while they need a good together time – it needs to be more than problem solving, to actually “being” with each other too. They also needed equally good away time so that they could come back to the relationship recharged. Chhavi and Prana tend to share a child-caregiver dynamic. Chhavi is often in need of reminders for relational care or care of their domestic life. Prana takes the caretaker role in their relationship, which has a flip side of making Chhavi feel suffocated or infantilised and Prana feeling like they are the only one being ‘mature’. Inadvertently, this led to a ranking of needs in the relationship, where Chhavi’s desires are viewed as shameful or needy, and infantilized and punished at times when Prana does not want to play the caretaker or gets tired of that role.

We discussed more about how these roles having become too rigid and both partners needed to shift their stance with Chhavi stepping up so that Prana does not feel like a caregiver and Prana needing to view Chhavi’s needs as a personal preference in intimacy and not be condescending towards her. The therapist also shared how Prana can step back from the caregiver role and let mistakes, forgetting, etc. happen without fearing loss of control and allowing for relational learning to happen through that, if they want to avoid feeling burnout as the caregiver.

Both of them got COVID one after the other, so meeting each other and doing some of the homework discussed, became difficult. The next few sessions were spent trying to identify the concerns with polyamory as well as the concerns with current relational patterns. We spoke of conflict being normal, and using the Gottman method to repair and de-escalate. The therapy sessions focused on how to not generalise the negatives to the entire person but keep it isolated to the behaviour at hand and watch out for contempt. The therapist also discussed how the distancer-pursuer cycle can become too familiar with time but may not be helpful to relational fulfilment. They discussed a few examples of when this had happened and the outcomes. The therapeutic space was also used to discuss that it’s not just about changing roles and going from pursuer to distancer or vice versa. Rather, it is about naming the uncomfortable emotions that drives that cycle – feeling fear, uncertainty, lack of love – and working with them directly. We did a few practice attempts within the session where they could talk about a concern while still staying loving towards the other, being clear about their needs and being flexible for the most suitable outcome.

After these few sessions and during the pandemic, they became irregular with sessions. The therapist had a suspicion that they were in a complacent state and the pandemic had made them numb their reactions to each other. So, they were probably back to a certain status quo, until something happens to bring the instability again. An incident followed that sparked and re-escalated their conflict. Chhavi was attracted to someone at a party and expressed romantic interest in them. When Prana saw this, they did not say anything and just began stonewalling Chhavi. They waited for Chhavi to bring it up. When she did, it led to a huge fight and they reached a stalemate again. This time, they came back to therapy admitting that they should have been more regular and committed to therapy which could also be a metaphor not just for therapy but also for being more attuned to each other, communicating better and trying to step out of older, rigid roles and patterns. Prana expressed anger and wanted polyamory off the table if they were to sustain the relationship in the future. The therapist discussed how ultimatums were not the solution and reflected on these threats being a result of intergenerational neglect from Prana’s parents.

Therapy focused on Prana’s pain and Chhavi responding to that rather than simply seeing Prana as rigid while she was pushing for polyamory. This helped Prana feel seen and heard. Chhavi shared that her goal was not to neglect Prana and was more an ask of expanding intimacy and sexual connection with others, in a safe way. They both spoke of different ways of spending time, bringing up sensitive topics, being emotionally present and also trying to understand each other’s historical trauma over time. This would help them both see where the other was coming from and respond in the most fruitful way, rather than just speaking to defend one’s position. Chhavi decided to give it 6 months to see how she feels about polyamory, and till then, both decided to give their fullest to the relationship at hand rather than focus on looming threats. If after this, Chhavi still felt like changing the format of the relationship, Prana promised to try and look at it differently rather than as a competition. They said they would look up polyamory and study it in a little more detail.

The therapist reflected on how she sometimes became a nurturer to Chhavi and the alliance became split such that Prana felt neglected. The balance was tricky and difficult and sometimes, the therapist’s own parents’ dysfunctional marriage would come to mind and make her feel on edge.

7.3.4 Special considerations for this population

Addressing issues in a queer relationship with AFAB partners, polyamory and commitment, issues of patriarchy/gender roles, etc. When people are socialised as girls or female children, there are certain traits that are encouraged and certain that are discouraged. Therefore, when we honour people’s gender identities, this part of their upbringing cannot be ignored. Secondly, whenever someone has a marginalised identity, they have often been wounded and deprived by society and their loved ones in many ways. Their suppressed feelings the testing and justice-seeking process can often come up in close and intimate relationships, sometimes as entitlement, and at other times as issues with commitment, communication, etc. Therefore, it is important to keep the deprivation and the related repetition compulsion in mind.

Having internalised cis-heterosexual ideas, queer people too can think of monogamy as better and purer and look down on polyamory as cheating, abandonment and a way to escape seriousness and commitment. These thoughts and beliefs need to be addressed side by side as we work on what it is that ideas like these evoke.

8. Conclusion

In this chapter, we delineate the continuity of attachment from infancy to adulthood to showcase how intergenerational patterns with early caregivers may present in romantic relationships. As differing attachment styles present in romantic relationships between partners, so too emerges the scope for understanding each partner’s attachment needs, increasing mutual attunement and emotional regulation. This brings into focus the scope for couples therapy. Interventions via promotive couples therapy is at the crux of developing more fulfilling relationships and increasing relational stability in couples of diverse ethnicities and genders or sexual orientations. These interventions are also applicable irrespective of marital status or length of the relationship. The efficacy studies we reviewed indicate that emotionally focused couples therapy, Gottman’s therapy and integrative behavioural couples therapy are a few of the key models with shared underlying mechanisms. These mechanisms include identifying individual needs, focusing on relational strengths, shared relationship visions and fostering a lasting emotional bond between partners. The three case studies review how three separate therapists (MI, MP and SV) utilise a shared process of relational history taking and conceptualization, focusing on individual relational needs and intervening based on the above therapeutic models. Case details were modified by the therapists to protect clients’ confidentiality. Through the writing of this chapter, we hope to bring more representation to diverse couples and highlight the scope of common factors, as they are implemented in relational therapies.

Acknowledgments

We sincerely thank Sadaf Vidha (SV) of Guftagu therapy for her contribution to the case studies.