Most psychologists or mental health professionals worth their salt will have some understanding about the research around what makes therapy successful for clients including co-regulation.
(If they don’t, then go find a professional who works from evidence-based practices!) What does the research say?
According to continuing research consensus, the strongest and most reliable predictor of successful outcomes for a client in therapy is the strength and quality of the relationship between the therapist and the client. In other words, the strength of feelings of trust, respect, positive regard, safety and goodwill between the therapist and you can reliably predict how well you do in therapy.
As a psychologist with training in attachment, this relationship, the therapeutic relationship between client and therapist, becomes a key focus of my practice.
Attachment theory
How can this therapeutic relationship influence good mental health outcomes for you and other clients?
You might have heard about attachment theory. Developed by John Bowlby and Mary Ainsworth, and developed further by Mary Main, attachment theory and research is the origin of commonly used terms like “insecure attachment”, “avoidant”, “dismissive”, “preoccupied”, “anxiously attached”, and “separation anxiety”.
Attachment has grown to play a central role in our understanding of the therapeutic relationship between a mental health professional and client.
Researchers such as Judith Herman, Allan Schore, and Peter Fonagy among others have contributed significantly in linking the scientific research around attachment with neurobiology and with what happens between a therapist and client in the therapy room.
According to attachment theory, our nervous system learns how to react to stress from the way our key caregivers respond to us when we are children. Depending on how our caregivers comfort, encourage, and help us to organise and understand our emotions, we develop differently.
We learn how to comfort ourselves and seek comfort from others when we are sad or ashamed, how to connect and seek safety and reassurance when we are scared of a threat, and how to manage feelings of anger when a threat feels unjust. In other words, our nervous system learns how to emotionally “regulate”. As a child, our caregivers teach us how to navigate our way towards safety, comfort, and connection, by co-regulating us. That is, as a child, we can’t do these things alone yet, and rely on our older caregivers to help us learn how to do these things in the safety of a trusting relationship.
But many (or most) of us don’t get many opportunities to learn some of these regulation strategies, often because our relationships with our caregivers didn’t feel safe or trusting. We had patterns of insecure attachment with our caregivers or just moments when our caregivers didn’t know how or didn’t have the capacity to help coregulate us when we felt big emotions.
Co-regulation in therapy
Psychological research increasingly speaks about how challenges with “emotion regulation” are at the heart of many different mental health conditions. We talk about emotion regulation as something mental health practitioners help clients with across different diagnoses (usually conditions involving anxiety and/or trauma).
A growing body of psychological research investigates how creating a safe and strong therapeutic relationship allows for clients to develop emotion regulation in the areas they need. The therapeutic relationship essentially provides the co-regulation for new secure attachment and emotion regulation to develop where it may not have had the chance to in the client’s life previously.
A good therapeutic relationship allows for you as a client to share emotion regulation challenges: fears, perceived threats, anxieties, anger and frustration, stress – all involving the activation of the nervous system. If there is a relationship of trust and safety the therapist can provide comfort, reassurance and safety, as well as encouragement, empowerment, validation, and organisation of feelings, that allow you to grow your own emotion regulation skills.
These are skills that can’t be developed alone; they have to be developed in the safety of a trusting relationship, through co-regulation of the nervous system.
The ideal therapist is one who can help guide you to self-regulation through co-regulation of the nervous system.
Take home message
The key takeaway – comfort, trust and feelings of safety with your chosen therapist are the most important thing. Give feedback on what you need to feel safe. Research indicates regular opportunities for feedback help to build feelings of safety. If you feel the therapeutic relationship does not have trust, respect or safety, even after feedback, it might be time to find another therapist.
That is not to say that you should abandon ship at the first sign you are feeling uncomfortable or unsafe. But the key is in how these feelings are responded to by the therapist. Attachment researchers and practitioners call it the “repair” to a “rupture” in a relationship. In other words, how two people try to reconnect and repair their relationship when there is a conflict.
This is all part of the coregulation experience in securely attached relationships.
What matters is not how we fight or fall out, but how we make up and restore connection and safety. This is the act that rewires our nervous system and teaches it to regulate. This is why emotion regulation is not something you can do alone! Only in relationship. And why healthy co-regulation is a precondition for healthy self-regulation of our emotions and nervous system.
For further reading on attachment in therapy, the nervous system, and the therapeutic relationship:
Attachment -The Basics in a few minutes read.
Shattered Shame States And Their Repair
Article summarising the themes here and their importance with key research. Renowned trauma expert Judith Herman on the role of attachment and co-regulation in healing shame and trauma.
For parents and adult children of parents! Practical guide to how attachment works in parent-child relationships and how to move from insecure to secure attachment relationships.
For the more deep-diving or science-minded – the neuroscience behind attachment and emotion regulation summarising recent research and theory in the area of interpersonal neurobiology.
For those interested in research on the therapeutic relationship (also called the “working alliance” or “therapeutic alliance”) see studies by Bordin, Hilsenroth, Horvath, Miechenbaum, Muran, Norcross, Rogers, Safran, and Wompold. These meta-analyses on adult and youth therapy are a good place to start, as well as the influential original metaanalysis from 1991.
By Sophie Georgeson
Find out more about Sophie on her profile here.