In this paper, we share a clinical case study of an adult with epilepsy, who has developed an insecure/ambivalent attachment pattern. Literature analysis indicate that attachment relationship experienced in childhood tends to expand into adulthood. The practical approach used in this case was based on cognitive narrative therapy, which the main goal is the (re)signification of experience and the construction of multiple meanings, promoting understanding of the personal role and impact of the experience for the Self. Cognitive narrative therapy can empower clients into understanding experiences and overcome relational difficulties that were inhibiting new experiences in a positive way. It was found that the client gradually began to be able to construct different narratives around her emotional experience in many aspects of her personal and emotional life, trying to build a progressively more organized narrative and filled with meanings.

Family is the first source of knowledge that the individual has in the world. The way people relate and interact with each other will help the child build an internal representation about herself and others. It is from the moment of birth that the individual initiates the development of attachment patterns with the attachment figures. Caregivers or parents are usually those who serve as attachment models for the child. When models do not adequately respond to the child needs, they do not facilitate the development of a trust relationship (or a secure attachment system) and, as a result, the child may develop some pattern of dysfunctional attachment, such as insecure ambivalent, anxious or avoidant coping styles. Without a secure attachment, i.e., when the child does not feel loved or capable of being loved, when her needs are not recognized or met by the caregiver, when she doesn’t use the attachment figures (father / mother) as a secure base, in order to proceed with the exploration of the environment, she could develop an anxious or ambivalent attachment pattern. Once felt the lack of response to her needs, the child blocks, or excessively activates, biological protection responses, making her more exposed to risks of diseases or psychological disorders. Stress and anxiety have been related to attachment patterns developed in childhood resulting, for the adulthood, in experiencing difficulties in future relationships, as they may develop an excessive anxiety, severe pursuit of social support and affection, or excessive fear of rejection. Liotti (1991, cited by Abreu, 2005) reported that affective bonds formed in childhood could extend to romantic relationships and even attitudes towards work. Simões (2007) developed a study about the theoretical evidences on the relationship between attachment and narratives. It was found that the use of cognitive narrative therapy can be an effective intervention strategy, since the sharing and elaboration of personal experiences works not only as a way of giving meaning to the experience itself but also as a way of creating and strengthening social and emotional bonds. In this paper we take a brief tour through the fields of the theoretical attachment framework and its impact in adult relationships. The case study is about a woman, in her thirties, who seems to develop an insecure/ambivalent attachment pattern, showing difficulties in creating and maintaining healthy relationships, especially romantic ones. She considers herself as being neglected in her childhood, and nowadays easily feels abandoned, thus this could be one of the reasons why she feels insecure in her adult relationships. This paper also aims to discuss the benefits of the use of cognitive narrative therapy in similar cases, when clients describe experiences as a chaotic trait. Psychotherapy intends to help the patient to reorganize his own narratives in a structured sequence and, in a long term, facilitate the construction of brand new and well-structured narratives.

Attachment – impact in adulthood

Mallinckrodt (2000) states that the perception of low parental support can lead to insecure attachment, which may result in some difficulties in social interaction, less ability to seek and establish friendships and difficulties in solving interpersonal conflicts. Other authors, such as Kanning (2006) suggests that an alienated relationship with parents does not create conditions to the development of interpersonal skills of young people and, consequently, these difficulties affect attachment in romantic relationships. A study by Assunção (2009) revealed that the better the quality of bonds created with both parents and youths, less is the dependency in youth romantic relationships. The study of attachment theory had large contributions from authors such as Mary Ainsworth (1969) and Bowlby (1988). The original model of Mary Ainsworth and colleagues point out some attachment styles or patterns that individuals begin to form in childhood, and these patterns can be secure or insecure. Within the insecure pattern there is the "avoidant" style and "anxious/ambivalent" style. These patterns seem to emerge in insecure contexts of social interaction and the child’s attachment behavior is followed by rejection or inconsistency from the attachment figure (i.e. parents or other caregivers). According to the attachment theory, these situations of inconsistency or rejection may result in some strategic child’s responses of hypo or hyper activation of the attachment system (Canavarro, Dias, & Lima, 2006). Bowlby (1988) proposed that children develop a set of expectations about themselves, about others and the world around them, what they called representational models or internal working models. These internal models or representations allow the child to predict and interpret the behavior of the attachment figure and would be used throughout life as an interpretative basis of her relational experiences (Canavarro, Dias, & Lima, 2006). These cognitive representations of the main attachment figure (parent), or relational schemas, shape the expectations of the adult in relation to subsequent relationships with peers and also to romantic relationships, guiding his behavioral responses towards a real or imagined separation of his new attachment figures (Pearson, 2006). When the individual spends his early life, in a family that shows low affection, with weak emotional resources, he or she could develop a poor perception of his ability to build and maintain personal relationships, thinking the problem is on them and the lack of ability to receive affection or even in weak "attractiveness". Hazen and Shaver (1994) also argue about a relation between the bonds that adults create in intimate relationships with those established with early attachment figures. As mentioned early, an insecure relationship towards caregivers may extend into adulthood, leading to insecure patterns in romantic relationships, which may result in constant search for affection and dissatisfaction about the emotional response from others. Moreover, this uncertainty may result in some adult emotional dependency, hesitant and ineffective behaviors in later relationships.

Narrative and Attachment

Simões (2007) refers to authors like Fivush and Vasudeva (2002), Nelson (1993) or Pillemer (1998), who propose that the function of remembering and sharing personal experiences with others is useful not only for searching the meaning of existence but also for the creation and strengthening of social and emotional bonds. Moreover, they propose that it is through the (co-)narrating past experiences, i.e. constructing a story with others, that we organize our knowledge and give a sense of temporal and personal coherence on the Self and the world. Simões (2007) also points out that other authors have conducted studies with dyads of children and parents, in order to investigate the attachment and narrative (such as Bowlby, 1988; Bretherton, 1985, 1990, 1999, Thompson, 2000), suggesting that there are associations between secure attachment and communication skills (either with attachment figures, or with others). Bowlby (1988) argues that one of the biggest aspects he found is that children with insecure attachment tend to exhibit difficulties in communication, emphasizing the concept of defensive exclusion, when too painful subjects for the child are erased from her consciousness and therefore not processed or not included in the narrative. Bretherton (1990) also believes that secure attachment is associated with a style of flowing and emotionally open communication, in which child can express a variety of emotions, thoughts and needs, both in the context of the attachment relationship, or in the speech about this relationship.

A study developed by Flores (1993) showed that children who lived in a chaotic environment were unable to describe events or narratives in a temporal structure, compared with other children with the same age. According to these studies, it is in the relationship with parents (or the main attachment figure) that children begin to construct a conjoint narrative, organizing experiences and meanings in their life.

Narrative cognitive therapy – the influence of constructivism

The human being has been considered, by several theoretical frameworks, as a meaning creator. In this sense, the construction and development identity will depend on the interpretations and representations that he makes about reality and his own experience. In fact, humans are authentic storytellers, and this activity involves the maintenance and development of thought, which is essentially metaphorical and imaginative (Gonçalves, 1998).  It is assumed that by the way the individual tells his own experience, it is possible to understand the multiple meanings that arise and the interpretations that he creates in each experienced situation. Cognitive narrative therapy is, in a few words, an updated version of cognitive therapy, being an approach that takes into consideration several cognitive domains. This approach considers the importance of taking into account the five senses to describe the experiences of life, as well as the description of feelings and thoughts and the use of metaphors to give those experiences a meaning (Soares, 2012). It gives language a special focus, in the therapeutic process, emphasizing the organization of discourse, the strategic use of words and concepts, which help describe the painful situation. A constructivist cognitive perspective, considers that when there is a psychological dysfunction, disturbance remains essentially in the Self. In the eminence of this dysfunction, when the individual is unable to understand the connections of the events of his past and his present life, or when there are critical aspects of the experiences that are not integrated into the narrative of his life, these personal narratives shatter and disintegrate (Neimeyer & Raskin, 2001). The main goal of using narrative cognitive therapy is, according to Óscar Gonçalves (2000, p.142), "to make the patient stop the vicious and apparently deterministic cycle of certain emotional and cognitive sets, leading him to the symbolization of a diverse number of internal experiences, to place them in a conversational and narrative context and, intentionally, build new modes of subjective experience." As mentioned above, the temporal organization of life events is jeopardized in people with attachment disorders, thus, it is a real challenge to think about and plan the future. As Mahoney (1998) said, an individual with insecure attachment pattern can only project for the future experiences that can be reminded in the present. So, he can only imagine receiving affection if he can also remember that same experience from his past.

Psychotherapy and attachment

Adult attachment is a concept that has been adopted in clinical psychology because of the growing number of studies that show a connection between insecure attachment patterns and psychological disorders (Daniel, 2006). One of the reasons that shapes the importance of working in attachment relationships in psychotherapy is that the client may reject or neglect his own suffering, i.e., he may use what Bowlby (1980) called defensive exclusion, putting back his attachment-related thoughts and feelings, which can make him more vulnerable to future psychological problems (Goodwin, 2003). It is known that internalizing the disturbance may constitute a risk factor for mental illness and influence subsequent relationships in a way that makes the individual more exposed and vulnerable to stress. Thus, an important aim of psychotherapy involves helping client to mourn his loss. This behavior of openness from client to therapist begins to shape itself as an attachment relationship, what we might call in psychotherapy the therapeutic alliance. Therapeutic alliance, according to Shaw, McMahon, Chan and Hannold (2004), is a collaboration process characterized by shared goals, tasks and attachment bonds, and is the best predictor of benefit in therapy (Platts, Tyson and Mason, 2002). Thus, the therapeutic relation, in psychotherapy, covers the basic human need of attachment, as well as the individual basic skill of learning through and inside a human relationship (Strupp, 1989).  Bowlby (1988) considers that, in psychotherapy, the therapist assumes the role of an attachment figure, allowing the establishment of a trusting relationship and providing the client a secure base from which he can explore his internal working models, also giving him the opportunity to reformulate them in this relationship. In this sense, the therapist should constitute a secure base for the client to explore more painful aspects of his life, which he couldn’t be able to deal with, without someone who he truly believes and gives him support, encouragement and orientation. Bowlby also formulated (as Davila and Levy, 2006, refer) some essential keys for psychotherapy, like, as mentioned above, the establishment of a secure base; the exploration of past attachments, expectations, feelings and behaviors; exploration of therapeutic relationship and the analysis of how it may be related to other relationships; exploration of the connection of past and present experiences; looking over internal working models and help the client to feel, think and act in different ways from his past experiences. Simões (2007) emphasizes that these internal models can be updated, taking into account the new experience that the therapeutic relationship constitutes. The change will be possible through interpersonal communication, in which narratives may offer the possibility of (re)defining the attachment experiences.

Clinical case study

Anna is a single woman around thirty years old, working in a management position. She shows difficulties in maintaining relationships. Anna has been adopted when she was around 5 years old, by a family with other children. Nowadays, she lives away from her adopted family because of her work, and admits that she hasn’t had a sense of belonging to that family. Although they have adopted her and took care of her, the best way they could, they show very few emotional content, which makes Anna feel unworthy and unloved, saying that she wishes a real family and, most of all, a father figure. Anna admitted that she shows opposite behaviors towards people she loves, such as compulsive caregiving or rejection, depending on the way she comprehends other people’s actions or intentions towards herself. However, she thinks that she is more likely to move away from people that show some affection for her, not being able to receive that fondness. Anna searched for help, initially, because of problems with her boyfriend, who also lives distant from her. She states she has trust issues and argues a lot with her. After some critical periods in the relation, Anna and her boyfriend tried to revitalize the relationship but with no success, since both started to blame each other for the failure of their attempts at reconciliation. Anna shows insecurity in her decision making about relationships. Her past relationships were never well resolved, which can be related to her constant search, although not in a conscious way, for a father figure. Curiously, Anna says that she has few friends, because during her life course she lost some of them, as she moved around a lot, or maybe because they weren’t “friends enough”. She shows lack of confidence and ambivalent feelings towards others, thinking that she gives much more than she receives. These thoughts, feelings and behaviors, like inhibiting or hyper activating emotional expressions towards the attachment figure are typically presented in individuals with insecure ambivalent attachment patterns (Berlin & Cassidy, 1999). Anna tried to communicate with her biological family but it has resulted in more defrauded expectations, since her mother doesn’t want to maintain a connection with her. These constant losses and deceptions made her even more insecure, worry and suspicious of her relationships, although she always tries to be strong and avoid showing suffering and anger towards her life events. Anna asks for help in order to be happy and build a family, without being afraid of suffering or being abandoned again.

Symptomatology and diagnosis hypothesis 

Anna seems to have developed depression symptoms, compulsive crying, isolation, panic attacks, showing sadness and no motivation on doing pleasure activities. Also, she shows difficulties in interpersonal relationships. After starting the therapy, Anna said that her panic attacks became different, since she had seizures and lost conscience. After going to the hospital, Anna said that doctors suspect from epilepsy, although the exams are still not conclusive.  In relation to her depressive symptoms, it is not possible to diagnose for mood disorders, since symptoms doesn’t seem to be clinically significant, mostly because of the duration of the events, which doesn’t correspond to the criteria for mood disorder. Also, her panic attacks doesn’t seem to correspond to anxiety disorder, because of the intensity and duration of the events. Anna says that her panic attacks don’t occur frequently and are often developed after a critical period (e.g. anger, fear, discussion). Considering the symptomatology it is important to note that, hypothetically, her symptoms (crying, isolation, panic attacks) may be a response to an attachment disorder, more specifically, because of her insecure/ambivalent attachment. Anna shows typical characteristics of a person who have developed an insecure attachment pattern, more specifically with an ambivalent style, such as the feeling of not being good enough, the constant looking for affection, the feeling of being neglected or rejected when attachment figure is not completely present or available, easily forming unrealistic expectations, excessive preoccupation and suspicious towards partner, compulsive caregiving and so on. Investigations in the twenty century, about childhood and adult attachment, suggested that, in Western society, around one third of adults have relationships characterized by anxious and insecure attachment (Holmes, 1993). Other interesting aspect in Anna’s case is the emergence of the epileptic seizures. We may hypothesize that this recent condition may be a symptom, related to the difficulty on talking about and bringing around her past traumas. Recently, a few studies have found a condition in which there is a sudden disruptive change in a person’s behavior, perception, thinking or feeling, and these factors have been mistaken for an epileptic seizure, although it doesn’t have the electrophysiological changes which accompany a true epileptic seizure (Carton, Thompson & Duncan, 2003). Therefore, these conditions seem to have a psychological etiology. People with non-epileptic attack disorder present with episodes which are similar to epileptic seizures but, in EEG analysis there are no signals of excessive electrical discharge of brain cells, which indicates truly epilepsy. In a literature review, Francis and Baker (1999) showed, through the results of other studies, that there are several differences between non-epileptic events and true epileptic seizures. These differences are, for example, the fact that many non-epileptic attacks may be precipitated by a trauma, contrarily to epileptic seizures; the beginning, in non-epileptic event, is sudden, and gradual in epileptic seizure; the duration of seizures are higher in non-epileptic events; cyanosis is unusual in non-epileptic attacks and common in epileptic seizures; also, weeping is present in non-epileptic events and absent in epileptic seizures. In a psychiatric perspective, non-epileptic attacks disorder were related to dissociative and converse disorders, which are linked to the concept of hysteria. From the eighties onwards, the interest in dissociation as a response to trauma had begun (Fiszman, 2007). Several authors, such as Carton, Thompson and Duncan (2003), consider that there are psychiatric morbidity in non-epileptic attack disorder, being depression the most common diagnosis. Not having the medical confirmation about epilepsy, as Anna says that doctors didn’t find deviations in her exams, this hypothesis may be important to understand her clinical case. A study developed by Akyuz and colleagues (Akyuz, Kugu, Akyuz & Dogan, 2004) revealed that experiences of childhood neglect may be related to non-epileptic attacks. Also, interpersonal difficulties, family dysfunction and early traumatic experiences are common in patients with non-epileptic attack disorder. This condition seems to be more frequent in fearful (or insecure) attachment styles (Holman, Kirkby, Duncan & Brown, 2008). In fact, it is not clear that the development of non-epileptic attacks is influenced by trauma itself or if there has an indirect effect through the development of other psychopathology (e.g. anxiety). 

Psychotherapeutic goals

Research about attachment theory and psychological treatment services for people encountering mental health problems, as a result of insecure attachments, focus on the psychotherapeutic process and relationship. Psychotherapy can be conceived as being based on the movement from insecure to secure attachment (Holmes, 1994), as the psychotherapeutic relationship may be an opportunity to develop security, intimacy and autonomy for the patient (Holmes, 1997; Vale Lucas et al 2014). However, this relationship construction is also a challenge, since the therapeutic process may be seen as a microcosm of attachment and separation, as the sessions are punctuated by endings and breaks (Holmes, 1997). Gonçalves (2008) presented a study where it was found that there is a positive correlation between secure attachment and therapeutic alliance, thus, insecure attachment might be a challenge for this alliance. Therefore, the psychotherapeutic goals should include the development of a trust relationship with the therapist; the construction of a secure base system, where the client can feel comfortable to talk and share fears and experiences; the insight of what is happening with her internal working models; help her to understand why she relates to others with an insecure pattern; develop a positive view of herself and her skills for give love and being loved; develop narrative skills that will help her to express feelings, thoughts, experiences and to facilitate the meaning attribution; the construction of a positive and constructive life project, mentally outlining positive future experiences.

Intervention 

The intervention, which is still in progress, is based on cognitive narrative therapy, since several authors (such as Bowlby (1988), Bretherton (1985, 1990, 1999) or Thompson, 2000) consider that there is a clear relation between cognitive narrative therapy and attachment styles. In this particular case, it is extremely important that therapeutic relationship is established, and that the therapist acts like a secure base. Also, this relationship will be important in order for the client to start learning to construct a coherent narrative, processing emotional content (such as anger and sadness) and being confident to share those kinds of emotions in the therapeutic relationship. These aspects, as well as the facilitation of self-exploration within the therapeutic relational context, have been considered as essential ingredients of psychotherapy with insecure clients (Holmes, 1994). According to Cassidy (2001), there are two fundamental aspects to develop a safe and functional attachment system, both aspects concerning the matter of trust. Firstly, it is imperious that the individual trust and believe that the other (the therapist, in this case) is available, sensitive and responsive to his needs. Second, and also important, it is imperative that the individual believes that he is lovable, that is, he must perceive himself as someone who can be loved and valued by others. Therefore, it was very important to develop these aspects in the very first contacts with Anna. The therapist clearly pointed out that the therapeutic context is absolutely secure, and encouraged Anna to develop a trust relationship with him.  The first sessions, after establishing the therapeutic goals, it was suggested some exercises of adjectivation of experience, as well as an exercise for selecting a particularly important event for each year of life. It was noticed that Anna reveals some difficulties in those kinds of exercises, which can be justified by her tendency for defensive exclusion, and because of her lack of temporal organization. Moreover, it was noticed some difficulties to identify emotions, feelings and thoughts particularly in painful situations, for example the moment of a panic attack. In the following sessions the same kind of exercise was proposed, so that the client could be able to identify and control these situations and to also find a metaphor that can easily help her express her own thoughts and feelings. The therapist also suggested Anna to keep a diary, where she writes down what she felt and thought in difficult situations. This kind of exercise would help her be more proficient in characterizing her own experience with adjectives, helping her to be able to identify specific reactions of her mind and body, to know herself better and develop trust in herself, since it would help her to know how to control her own behavior. Still, Anna showed some initial difficulty in finding time to write but, gradually, she seemed to recognize that it might be helpful and started to write in intense moments, saying that writing was like an escape, just like if she was telling others her feelings, and that felt really good. Her narratives, oral or written, were very reflexive. She started to understand that the way she relates to others is a reflection of what she has lived in early years, and that her behavior towards others can change if she believes in herself as a person who is capable to be loved, trying to change her problematic narrative to a positive one. Also, it was important to work with Anna her losses, as she needs to understand that they are very similar to the death of someone she loved, since the idea and the expectations that she had towards her two families, boyfriends and friends, have been broken, and so she needs to initiate a grief process. This new meaning construction and the use of metaphors to understand her own experience is considered a central aspect for the psychotherapeutic change (White & Epston, 1990; Soares et al 2013).  To truly move on to a brand new narrative, it is important that the client  identifies and recognizes every single loss as an attempt to revive the anger, the pain, the anxiety, since that helps to give a meaning to that loss. An important author in the field of losses and grief, Neimeyer (2001, 2006, 2012) and Paiva et al (2025) states that it is important that  the person must be capable of reformulating meanings, so she can integrate the loss. Also, he argues that as a novel that loses a central character in the middle of the action, life stories affected by losses have to be reorganized and rewritten to find a new future. Neimeyer consider that unsent letters may be a relevant therapeutic writing activity, since it reopens the dialogue with people who the client lost, addressing some questions, fears or thoughts. Such exercises would help Anna in giving new meanings to her losses, to close unresolved chapters in her life and to bring some peacefulness to her, facilitating the construction of new relationships.  Simultaneously, it is important to help the client to design new and positive future goals, which is a real challenge, as mentioned above. Óscar Gonçalves (2000) mentioned the challenge of thinking about future goals in a particular phase of narrative therapy described by him, citing a few authors such as Markus and Nurius. They refer to the importance of exploring "possible selves", focusing on the possibility for the client to open himself to experience, to create new narratives, making a proactive construction of a greater variety of content. Gonçalves (2000) also speaks on the concept of "projection", where the term "project" refers to the notion of a moving object, since the individual is himself that object, an active participant of his own experience, a constructor of multiple narratives. Thus, the therapeutic work with Anna, also focus this aspect of projection, helping her to visualize herself in positive scenarios and engage in constructive narratives. Therapeutic change is still occurring, and narratives are being progressively more adaptive and positive, as the client starts to understand her importance in changing and creating her own future.

The narrative gained importance in the field of psychotherapy, as it is acknowledged that finding new meanings for experiences is a good predictor of therapeutic change. Moreover, trust and confidence are central keys for individuals to relate positively, so a truly attachment relationship is needed in the therapeutic context. People with an insecure/ambivalent attachment pattern tend to present a disorganized narrative as well as feelings of insecure and lack of love. These disruptive situations, adding to important losses in life, may lead to difficulties in the relationship with others, as the individual will not believe in positive events in his life. 

This work shows a clinical case study where the client lost some of the most important bonds in her life, and seemed to develop an insecure/ambivalent attachment pattern. Because of that, some important symptoms emerged and they are important signs of dysfunction and suffering. The psychotherapeutic intervention focused on cognitive narrative therapy, where constructivism and attachment theory play an important role, helping the client to redefine, reorganize and reinterpret her meanings of her life events. It´s an opportunity to rediscover herself in a brand new and positive relationship in the therapeutic setting, since she started to feel more capable to relate with the therapist and talk about herself and her experiences in a constructive way. This relationship is almost a training process, where the client knows herself better and visualizes, with the therapist help, how she relates to others, and how she can change the way she sees others’ intentions towards her.