No More Learning

The therapeutic alliance and the 'real' relationship
Zetzel (1956) was the first to use the phrase the 'therapeutic alliance' to describe the non-neurotic, reality-based aspect of the therapist-patient relationship (Mackie 1981), a term which is usually used interchangeably with that of the 'working alliance'. Greenson (1967) sees the 'reliable core of the working alliance in the "real", or non-transference relationship'. By 'real' is meant both genuine and truthful as opposed to contrived or phoney, and also realistic and undistorted by phantasy.
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In practice these distinctions are not so easy to make. The patient may well have a genuine desire to get better and to collaborate with the therapist in doing so, and at the same time be concealing feelings of despair and disappointment behind an idealising transference. It is certainly the therapist's task to provide a secure base for the patient: to be available regularly and reliably; to be courteous, compassionate and caring; to be able to set limits and have clear boundaries; to protect the therapy from interruptions and distractions; and not to burden the patient with his own difficulties and preoccupations. Since Attachment Theory presupposes that a distressed individual will naturally seek security, the distinction between the 'real' and the transferential relationship becomes less problematic. Dependency on the therapist is not seen as inherently neurotic, but as an appropriate response to emotional distress. The issue is whether the patient has formed a secure or an anxious type of attachment, and if anxious, what pattern. If, for example, there has been major environmental trauma in the patient's life (prolonged separation from parents, or physical or sexual abuse, for example), then the patient is unlikely to find it easy to form a secure base and may in an avoidant way approach therapy and the therapist with suspicion and reserve, and detach himself at the faintest hint of a rebuff, and the 'real' relationship may hang by a thread.
The question of whether attachment to the therapist is merely a necessary first step for the initiation of transference or whether it constitutes a therapeutic element in its own right is usually understood in terms of stages of development. Balint's 'basic fault' patient (that is, one who is severely damaged by early environmental failure) needs a new kind of empathic experience with the therapist which can then be internalised and so provides an inner sense of security which is the precondition of autonomy. In a less damaged 'Oedipal' patient, attachment to the therapeutic environment can be more taken for granted, and the focus will be on the way that the person of the therapist is viewed and treated. Kohut (1977) and Guntrip (1974) have pointed to the difference in technique required for these two types of patient, arguing that more damaged 'borderline' patients require greater acceptance and environmental provision. Kernberg (Bateman 1991) has questioned this, claiming that limit setting and interpretive understanding is even more vital if these patients are to be helped towards adaptation to reality.
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Bowlby rejected a simplistic 'stage'-based model of development, but the distinctions which attachment therapy makes between ambivalent, avoidant and disorganised patterns of insecure attachment are relevant here. The disorganised pattern may represent the most disturbed patients who are threatened by too close attachment of any sort, and need a low-key supportive approach (Holmes 1992). The ambivalently attached need a combination of absolute reliability and firm limit setting to help with secure attachment, combined with a push towards exploration. The avoidant group associate close contact with pain and rejection and may experience interpretations as intrusive assaults, and so benefit from a more flexible and friendly therapeutic relationship.
Balint's (1968) distinction between 'ocnophils' (clingers) and 'philobats' (avoiders) corresponds closely with Bowlby's classification of insecure attachment into ambivalent and avoidant patterns. Balint sees many psychoanalysts as 'ocnophilic', clinging to their patients with their interpretations. Like Meares and Hobson (1977) in their discussion of the 'persecutory therapist', he argues that attachment must be sought and accepted as a goal in its own right with more disturbed patients, and that too much interpretation can inhibit a patient's exploration.
Spying or seeking
Annabel was a disturbed young woman living away from home in a bedsitter. She had always felt that her mother favoured her brother over herself. This feeling of exclusion was compounded when, during her teens, her mother became ill and her previously neglectful father had tenderly looked after his sick wife. Annabel confessed to her therapist that one day when alone in the house she had crept into her landlady's part of the house and, searching through her desk, had found some love-letters from her husband and had read them avidly.
A Kleinian interpretation might have focused on the envious 'attack on linking' implicit in this act, trying to help her to get in touch with the angry and destructive impulses which made her feel responsible for her mother's illness. A Bowlbian approach, however, would see the need to maintain a line of attachment as paramount, and would therefore interpret this act as a search for a secure base in her parents' marriage (and by transference in the
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therapy). Only once this secure base was firmly established would it be appropriate to look at her protest about loss and separation. As we mentioned in Chapter 3, Attachment Theory is essentially a spatial theory in which the care-seeker is constantly monitoring and adjusting his distance from the care-giver depending on the level of perceived anxiety and the strength of the drive to explore. Balint also emphasises the importance of getting the right distance from the patient, especially if words fail and the patient falls silent. The therapist must be
felt to be present but must be all the time at the right distance - neither so far that the patient feels lost or abandoned, nor so close that the patient might feel encumbered and unfree - in fact at a distance that corresponds to the patient's actual need.
(Balint 1986)
Therapists and parents
Post-Bowlbian research has begun to provide a picture of the kinds of mother-infant interaction that are likely to give rise to a secure base experience for the growing child. The children of parents who are responsive and attuned and see their infants as separate are likely to be better adjusted socially, more able to reflect on their feelings and to weave their experience into a coherent narrative. The capacity to handle loss and separation with appropriate anger, sadness and reconciliation is associated with secure attachment. These findings can be compared with the Rogerian view that effective therapists show empathy, honesty and non-possessive warmth (Truax and Carkhuff 1967). The good therapist acts, mainly at an unconscious and non-verbal level, like a good parent with his patients. Empathy corresponds with attunement and responsiveness; honesty ensures that negative feelings, especially those connected with loss and separation based on the inevitable failures of the holding environment in therapy (therapist's illness, holidays, memory-lapses and so on), are dealt with openly and without prevarication; non-possessive warmth means that the therapist gets the attachment distance right which means they are containing to the patient without being intrusive.
Based on Attachment Theory research we can identify three component elements which go to make up the secure base phenomenon in therapy: attunement, the fostering of
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autobiographical competence and affective processing (Holmes 1992). Two case examples will now be given to illustrate the phenomena of attunement and autobiographical competence in therapy. Affective processing will be considered in a later section of the chapter.
Attunement
Stern (1985) sees attunement as the basis for the emerging sense of self in the pre-verbal infant:
Tracking and attuning . . . permit one human to be with another in the sense of sharing likely inner experience on an almost continuous basis. . . . This is exactly our experience of feeling- connectedness, of being in attunement with another. It feels like an unbroken line. It seeks out the activation contour that is momentarily going on in any and every behaviour and uses that contour to keep the thread of communication unbroken.
(Stern 1985)
For Stern, the emotionally disturbed patient is one whose early experiences lacked this attunement. There is perhaps a faint echo of Hamlet's farewell to Horatio when he compares the need for an attuning parent (or therapist) with
the continuing physiological need for an environment containing oxygen. It is a relatively silent need of which one becomes aware sharply only when it is not being met, when a harsh world compels one to draw one's breath in pain.
(Stern 1985)
Brazelton and Cramer's (1991) detailed description of secure parent- infant interaction similarly delineates the components of responsive interaction: synchrony, symmetry, contingency and 'entrainment', from which mutual play and infant autonomy begin to emerge (see Chapter 6). These features are equally applicable to therapist-patient interactions. Good therapists find themselves automatically mirroring their patients' levels of speech volume and their posture. Malan's (1976) concept of 'leapfrogging' between patient and therapist is very similar to the idea of contingency and entrainment in which parent and child hook onto each other in sequences of mutual responsiveness. This can be
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demonstrated immediately in videotapes of therapy, but is less easy to convey in a written account.
Sarah's 'ums' and 'aahs'
Despite marriage, parenthood, a profession and a circle of good friends, Sarah had reached her fiftieth year almost without any sense of who she was or what the meaning and direction of her life should be. In her social self she played the part of a cheerful and active woman constantly fighting off feelings of depression and the wish to end her life. In therapy she returned again and again to the question, 'Who am I? '.
She had been brought up in a 'progressive' children's home where her parents were the proprietors. She had always felt that her mother was 'so near and yet so far': she could see her, but was expected, from the age of three, to fit in and share a dormitory with the other children, and was not allowed to have any kind of special relationship with her. Her father was harsh, distant, controlling and physically and sexually abusive. She dated the origin of the split between her 'social' and her 'real' self to the age of eight, when she had nai? vely tried to disclose her father's abuse but had been disbelieved, and punished by him for what to her was quite inexplicable 'wickedness'. Any attunement between her inner world and the external one was fractured from then on. Peer Gynt-like, she complained that however much she peeled away the onion skin of her existence she could never find her real self.
As therapy progressed she found the 'attuning' sounds of the therapist - the 'ums' and 'aahs', grunts, inhalations and exhalations - immensely comforting. 'They give me a sense that somehow you know how I feel, however much you appear distant, rejecting or uninterested (all words she had used about her parents) in your verbal comments. ' In fact, it was extremely difficult to tune into this patient, who varied between desperate attempts to draw the therapist into her pain and misery, complaining ('Why aren't you angry about the terrible things that happened to me as a child? '), demanding ('I need to know that you like me'), and excluding him with a self-absorbed, miserable monologue. Nevertheless, the fact that she could complain, demand and moan was, for her, in itself a considerable achievement. She dreamed of the therapist looking at her and knowing, without her having to
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put it into words, how she felt, and of his gently putting an arm around her in a gesture of protection.
Autobiographical competence
Winnicott (1965) described psychotherapy as 'an extended form of history-taking'. The patient comes with a story, however tentative and disjointed, which is then worked on by therapist and patient until a more coherent and satisfying narrative emerges, which provides an objectification and explanation of the patient's difficulties, and a vehicle or symbolisation which links inner and outer experience (Spence 1982; Shafer 1976). Tulving (Eagle 1988) distinguishes between 'semantic' memory, which is propositional and influences behaviour but which need not necessarily be conscious, and 'episodic' memory, which has a narrative structure and consists of stored chunks of remembered experience. The process of therapy can be seen as one of making 'semantic' memory episodic, of weaving a narrative out of the unconscious attitudes, assumptions and affects which the patient brings to the therapy in the transference, so that they feel they now own them.
The avoidant patient with a dismissing autobiographical style begins to allow some of the pain of separation into consciousness, the ambivalent patient with a preoccupied style can start to feel safe enough to let go of their past anguish. Out of narrative comes meaning - the 'broken line' of insecure attachment is replaced by a sense of continuity, an inner story which enables new experience to be explored, with the confidence that it can be coped with and assimilated. The next example tries to illustrate the immediacy of this process by presenting material from a single session.
Peter: stringing a story together
Peter is a man in his late fifties, now in his second year of weekly therapy. He has a very strong presence: powerful, pugnacious, a self-made man who grew up in the Gorbals, he is now a ship's captain, away from home for long stretches of time. His problems are depression, marital conflict and suicidal feelings which have been present for many years but which came to the surface after the birth of his youngest child.
He starts the session by talking about money. 'I'm like my father, always worrying about money. I'm feeling good today,
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I've bought a car cheap, and I've got some work. ' But that means another break away from home and from therapy. A lot of therapeutic effort has gone into helping him recognise how he detaches himself from feelings of loss when he goes away. 'I used to pride myself on not bothering to ring home or to miss them when I was away - it's only two weeks, why make a fuss. '
I take up the implication that in one sense therapy has made things more difficult for him now that he is in touch with feelings of loss and separation rather than cutting off from them, and remind him of the misery which he described when as a child he was evacuated to the country during the war, away from the bombs but also from his mother.
'Yes, it was terrible. After a few weeks my mother came to collect me. Did she dote on me or what? Everyone says that she did, but I just can't remember. ' He then goes on to list a string of incidents which we have already unearthed and discussed from his childhood - playing truant at the age of five without his mother knowing, feeling an outsider among his playmates, learning to establish himself through fighting - 'Who is that little boy, I just don't recognise him; is that me? ' He jokes: 'Oh well, like my father used to say, nostalgia's like neuralgia. '
I suggest that he can't piece himself together, can't identify with the little boy that he was because his mother wasn't there to string the episodes of his life together for him, just as I won't be there when he goes off to work next week.
He protests: 'But I can get what I like from women', and gives several examples to prove his point. I reply by wondering if he feels these women really know him, whether he feels that I or his wife know him, if his mother really knew his sadness and fear. Perhaps it was his vitality and strength that she doted on, like the women he can get what he likes from, not his vulnerability.
He then recounts some new history about his mother's childhood, how she was illegitimate, the offspring of his grandmother's second 'husband', how his grandfather had been quite well off, loved opera (as he does) and had taught his mother to play the piano, how she had been only eighteen when she became pregnant by his father and they 'had' to get married.
I suggest that his confusion about whether or not his mother 'doted' on him was perhaps because she was depressed during his infancy, confused in her new 'legitimate' identity, just as he had become depressed after the birth of his youngest child.
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There was a pause: it seemed that this had struck a chord. 'Click: they always used to say what a difficult feeder I was as a baby. My father' (the father who had always told this highly intelligent man what a dunce he was) 'had to buy special milk for me. '
I said: 'So money goes to the heart of your identity. He worked to keep you alive, just as you see me working to keep you alive now. '
He began to weep. I wondered if his sadness was to do with the coming break. 'No,' he said, 'It's gratitude - you seem to recognise what I am like. '
Seen from this post-Bowlbian perspective the tension between attachment and interpretation as curative factors in psychotherapy becomes less problematic. The responsiveness of the therapist begins to restore the 'broken line' of the patient's internal world and forms the basis of a secure therapeutic base. This enables the beginnings of exploration which in the setting of therapy takes the form of a narrative in which the therapist's interpretations are an attempt to modify, expand and lend coherence to the patient's story. But the narrative is not just the patient's 'case history'. It is also the history of the therapeutic relationship itself, of the movement from what Balint (1968) calls the 'mixedupness' of patient and therapist to a state of differentiation in which the patient detaches himself from the external support of the therapist and comes to rely on his own internal secure base, with a less fractured line of self.
2 REALITY AND TRAUMA
The notion of the 'broken line' brings us to the question of trauma in the genesis of neurosis. We saw in the last chapter how Bowlby's psychoanalytic education took place in an atmosphere in which the role of external reality was seen as largely irrelevant, compared with the influence of phantasy in mental life. Bowlby found this incomprehensible and reprehensible, and in one sense his life's work could be seen as an attempt to prove Klein wrong on this point.
His model was a rather simple, common-sense one, based on Freud's early views, in which neurosis is the result of trauma, the facts or emotional implications of which have been repressed. The task of therapy is primarily that of undoing this repression in
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a non-judgemental and accepting atmosphere. This must be contrasted with Freud's mature views and those of contemporary psychoanalysts. Here the crucial factor is the interaction between environmental failure and the child's phantasy life. What makes trauma traumatic is, as Symington (1986) puts it, 'when reality confirms the phantasy'. In the Oedipal situation the child feels that his attachment to the mother is threatened by her relationship with his father. He may harbour feelings of hatred towards him, and have angry outbursts at home or at school. If he is then in reality beaten by his father - say, because of this recalcitrance (or, conversely, there is no father to help him detach himself from his mother) - then his internal world will be deformed and he is likely to be mistrustful of attachment while secretly yearning for it. This will affect his subsequent relationships, which may be characterised by demandingness, violence or detachment. If, on the other hand, his original feelings of fear and rage were accepted by the parents, the outcome will be favourable. A similar story can be imagined about the frustrations of infancy: a mother's actual unreliability and inability to accept the child's protests without retaliation will solidify rather than modify an already split inner world, and lay the foundations for 'borderline' patterns of relationships in which good and evil are kept unstably apart and compromise and balance are inaccessible (see Chapter 9).
Bowlby's own research and the accumulating evidence that parents do indeed abandon, neglect, physically and sexually abuse their children, and often deny that they do so and prohibit protest about the distress they have caused, seems to support his position that trauma and loss are central to the genesis of neurosis. Against this must be set several important qualifications. First, as we saw in Chapter 3, there are not a few resilient children who, despite apparently appalling environmental traumata, appear to come through without major psychological damage (Rutter 1985). Second, seeing people merely as victims of their circumstances, although valid at one level leaves out the idea of agency, which is a vital ingredient of psychological health. It also fails to comprehend the way in which pathological patterns, once internalised, are perpetuated by the sufferers themselves: the vicious circles of neurosis in which mistrust breeds disappointment, avoidance invites neglect, clinging provokes rejection, depressive assumptions lead to negative experiences which confirm those assumptions (cf. , for example, Beck et al.
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1979; Strachey 1934; Ryle 1990). Third, merely commiserating with a patient about the ways in which they have been damaged by their parents or by traumatic events does not in itself necessarily produce a good therapeutic outcome. For that to happen there has also to be some re-living (before relieving) of the emotional response to the trauma, and it is a central task of psychotherapy to provide the setting in which this affective processing can take place.
3 AFFECTIVE PROCESSING
Bowlby's early work seemed to imply that separation, at least in the first five years of life, was inherently a bad thing, and that a major task of preventive psychiatry would be to minimise the occurrence and affects of such separations. In his later work, however, there is a shift of perspective so that it is not just the facts of loss and separation, but the nature of a person's emotional response to them that matters. The Adult Attachment Interview findings (Bretherton 1991b) suggest that loss that is either denied (dismissive pattern) or cannot be transcended (preoccupied pattern) is associated with insecure attachment (see Table 8. 1). The way a parent handles a child's response to separation is a key factor here - whether by accepting and encouraging the expression of feelings of anger and sadness, or by sweeping them under the carpet. Bowlby saw the task of the therapist both to encourage appropriate emotional response to past trauma, and to be alert to the ways in which the patient is reacting to the losses and separations in therapy and to encourage discussion and ventilation of feelings about them. His views are well illustrated in his discussion of Charles Darwin's lifelong symptoms of anxiety and psychosomatic illness.
Charles Darwin: loss denied
Bowlby (1990) explained Darwin's lifelong intermittent psychosomatic symptoms of palpitations, paraesthesia, exhaustion and faintness in terms of unmourned loss. His mother died when he was eight. His father, a busy and irascible country doctor, whose own mother had died when he was a child, handed Charles over to the care of his older sisters, who forbade any mention of their mother's death. So powerful was the effect of this prohibition
Table 8. 1 Clinical aspects of insecure-avoidant and dismissive attachment
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that, at the age of thirty-three, in a letter of condolence to a friend sympathising about the death of his young wife, he wrote: 'I truly sympathise with you though never in my life having lost one near relation, I daresay I cannot imagine how severe grief such as yours must be. '
Another instance of the repression of painful affect in Darwin's life comes from his granddaughter's account of a family word game in which words are 'stolen' by one player from another if they can add a letter so as to create a new one. On one occasion Darwin saw someone add an 'M' to 'other' to make 'Mother'. Darwin stared at it for some time, objecting: 'There's no such word as MO-THER'! (An unpsychological explanation such as Bowlby's parents might have offered was that Darwin was a notoriously bad speller - Raverat 1952. )
Bowlby sees Darwin's chronic ill health as reflecting two sets of unresolved conflict. The first was his inability to grieve, to bear the pain of the many losses in his life, starting with that of his mother, and including his wife's many pregnancies (sources of great anxiety to Darwin) and the loss of their beloved eldest daughter in 1851. The second was his ambivalent relationship with his overbearing father, whom Charles both revered and feared. Bowlby sees his hesitancy about publication of The Origin of Species (it took nearly twenty years between writing the original draft and publication, which was spurred on eventually by competition from Wallace) as reflecting this compliance and defiance in relation to authority. Bowlby's recipe for helping Darwin to overcome his difficulties would have been to 'recognise and gradually counteract the powerful influence . . . of the strongly entrenched Darwin[ian] tradition that the best way of dealing with painful thoughts is to dismiss them from your mind and, if possible, forget them altogether'. Thus does Bowlby recruit Freud to help with the Englishman's Achilles' heel - his fear of feelings.
Bowlby and Winnicott: to commiserate or not?
It is interesting to compare Bowlby's ideas with those of Winnicott on this point. Winnicott opposes any reassurance or commiseration about trauma from the analyst, on the grounds that they may inhibit the affective processing that is needed if therapy is to succeed. He bases this on a rather subtle argument about the infant's necessary illusion of 'omnipotence', based on
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the mother's sensitive anticipation of his needs so that just as he is, as it were, thinking he might be hungry, the breast miraculously appears, as though by magic. For Winnicott the origins of creativity are to be found in this interplay between mother and child. Like Bion (1978), he also sees the mother helping the infant to deal with bad feelings through her containing and transmuting functions. If the baby feels that his protest and anger are accepted and held, then the environment does not 'impinge' in a traumatic way: 'The ego-support of the maternal care enables the infant to live and develop in spite of his not yet being able to control or feel responsible for what is good and bad in the environment' (Winnicott 1965).
Like Bowlby (but unlike Klein), Winnicott seems to acknowledge that the environment can let the child down, but argues that the child needs to have felt that everything is under his control before he can come gradually to accept his vulnerability:
The paradox is that what is good and bad in the infant's environment is not in fact a projection, but in spite of this it is necessary . . . if the infant is to develop healthily that everything shall seem to him to be a projection.
(Winnicott 1965)
This viewpoint enables Winnicott to argue the case for an analytic attitude in which the trauma is re-experienced in the transference in such a way that it comes within the area of 'omnipotence':
In psychoanalysis there is no trauma that is outside the individual's omnipotence. . . . The patient is not helped if the analyst says 'your mother was not good enough . . . '. Changes come in an analysis when the traumatic factors enter the psychoanalytic material in the patient's own way, and within the patient's omnipotence.
(Winnicott 1965)
Winnicott's phrase, 'bringing into omnipotence', is an example of the combination of clinical accuracy with theoretical fuzziness that Bowlby was keen to remedy in psychoanalysis. It also reflects Winnicott's ambivalence about Klein. He is straining both to be true to his clinical experience (that what is good and bad is not a
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projection) and to remain faithful to Kleinian theory (which emphasises the 'omnipotence' of infantile thought). A behavioural way of looking at this is to see it as an example of 'state-dependent learning' - that is, the observation that some things can only be learned, or unlearned, when the emotions associated with them are re-experienced. Humphrey's (1992) recent distinction between perception, an appreciation of the state of the world 'out there', and sensation, the state of things 'in here', is also helpful. While perception is a mirroring of external events that happens willy- nilly if the organism is to survive, and can be conscious or unconscious, Humphrey sees sensation as an active process in which the subject, as it were, presents his feelings to himself and that this is quintessentially a conscious process. One can imagine that sensation is, in the early stages of life, a shared activity between parent and child as the experiences of holding, seeing, feeding and touching are presented to the growing child. As Garland (1991) argues, traumatic events overwhelm the 'stimulus barrier' so that, although perceived, they cannot be sensed. The subject is paralysed by them and cannot actively present them to themselves, while the parent or protector who might help to do so is inevitably absent. The task of therapy then is to 'represent' these traumatic events - via a narrative transformation from 'semantic' to 'episodic' memory - in such a way that they can be sensed, and therefore, by definition, made conscious. This process could possibly be described as 'omnipotent' in so far as any representation or map, including the cerebral 'map' of feelings, is 'omnipotent'. Thus a grain of sand could be said omnipotently to 'contain all heaven'. Here is an example of such emotion recollected in (comparative) tranquillity:
The tonsillectomy
A man in his thirties entered therapy because of his feelings of depression and a failed marriage. His relationships were characterised by avoidant attachment.
He was always seemingly throwing away the very things that he wanted. He knew what he did not want, but not what he wanted. Whenever his career threatened to take off he would leave his job. A similar pattern affected his relationship with his partner: the closer they became the more likely there was to be a violent argument. He was an only child whose father had been killed in the war, and the origins
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of this pattern seemed to go back to his mother, on whom he was very dependent, but whom he experienced as intrusive and interfering.
One winter's day as he was waiting for his therapy session he saw the therapist through the closed window breathing steam into the cold air. He found himself worrying that the therapist might have something wrong with his lungs. Suddenly a flood of memories returned a tonsillectomy he had undergone when he was five. Visiting was restricted (these were normal regimes in those pre-Bowlbian days), but he was able to see his mother through a glass window twice a week (it may not have been that bad - this was how he recalled it). He remembered his fury at not being able to go home with her, throwing the toys she had left for him, shouting 'I want my mummy . . . '. As the memories returned so he began to cry profusely. This session was a turning point, enabling him to move from a position of 'I don't want . . . ', to 'I want . . . '. The traumatic separation had been re-experienced in the therapy, and no longer needed to be enacted via projective identification (doing to his employers and girlfriend what as a child he had felt had been done to him by his mother) but could be symbolised and so become part of the therapeutic narrative.
Therapists out of touch?
Attachment Theory throws an interesting light on the dilemma posed by the problem of touch in therapy. Bowlby emphasises the importance of real attachment of patient to therapist. Because attachment needs are seen as distinct from sexual or oral drives there is no intrinsic danger of gratification or seduction. Attachment provides a quiet background atmosphere of security within which more dangerous feelings can be safely explored. The patient who asks to touch the therapist, to hold a hand or be hugged, is wanting to get hold of the 'environment mother' who let him down or was absent in childhood, and it may be legitimate in certain circumstances, and with appropriate ethical safeguards (Holmes and Lindley 1989) for the therapist to respond to such a request (Balint 1968). In 'Attachment and new beginning', Pedder (1986) describes how a patient who had been separated from her mother for 6 months in infancy
buried her head in the pillow, extending her arms out loosely to either side of the pillow. Her hands moved around restlessly,
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reaching silently in my direction for some ten minutes. Eventually I said I thought she wanted me to take her hand, though she felt unable to say so, and then I did.
This seemed an important new beginning and she was later able to say how she had been terrified of being too demanding in asking me to hold a hand, fearing I might not trust her and might have mistaken her wish to be held as sexual.
(Pedder 1986)
Secure attachment to the therapist may be part of a 'new beginning' for certain patients, and some physical expression of this can be helpful. But - and here is the dilemma - pain and anguish of separation also need to be re-experienced if the patient is to feel safe enough to form new attachments, secure in the knowledge that, should things go wrong, the loss can be mourned and that he will not be left feeling permanently bereft.
Winnicott's view that trauma needs to be brought 'within the patient's omnipotence' is echoed by Casement (1985) in his discussion of another case in which the patient had asked to hold her therapist's hand. This was a woman who had been badly burned as a child and whose mother had fainted while holding her hand when the burn was being operated on under local anaesthetic. After initially agreeing, Casement later decided not to accede to the patient's request. This withdrawal led to fury and near-psychosis in the patient, but once this had been survived she began rapidly to improve, and it seemed that the uncanny repetition in the transference of the mother's holding and then letting go of the patient, while remaining in a therapeutic context that was basically secure, had contributed to this breakthrough. Casement quotes Winnicott:
the patient used the analyst's failures, often quite small ones, perhaps manoeuvred by the patient. . . . The patient now hates the analyst for the failure that originally came as an environmental factor, outside the area of omnipotent control, but that is now staged in the transference. So in the end we succeed by failing - failing the patient's way. This is a long distance from the simple theory of cure by corrective experience.
(Winnicott 1965)
Bowlby the scientist was always parsimoniously trying to devise a 'simple theory' with which to explain the enormous complexity of intimate human relationships. Attachment Theory, while in
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general being unworried by physical contact between patient and therapist, does provide a clear rationale for exercising extreme caution in dealing with patients who have been abused in childhood, as the next example illustrates:
Safe breathing: secure base
Sarah, of the 'ums' and 'aahs' discussed above, was increasingly distressed as her elderly mother became ill. This coincided with her therapist having to change the time of her appointments. She started to sob and shake and overbreathe during the sessions. She wrote a poem in which she longed for a pure and childlike intimacy with her therapist. She wanted him inside her, breathing him in through her lungs, rather than taking him in through her mouth or genitals which she saw as sullied and contaminated. She wanted desperately to hold his hand, but he intuitively felt that this would be wrong.
When patient and therapist looked at this together they realised that this was because, as well as being the secure-base mother she so longed for, he also represented the abusive father whom she feared and loathed. Had he held her hand this would have repeated the typical abusive vicious circle in which the child clings ever more tightly to her abuser: the abuse creates a terrible anxiety which leads to attachment behaviour, which provokes more abuse and so on. By holding his hand she would have remained an object, albeit one in need of protection, whereas her greatest need was to become the subject of her own life, even though this meant subjecting herself to intense pain and fear. In the end she soothed herself with the idea that if she could feel that she belonged for a while in his consulting room, things would be all right. Like Oliver Twist (see Chapter 3), she needed first to find a place to which she could become attached, before she could begin to own her story.
4 COGNITION IN THERAPY
We have argued in the previous chapter that Bowlby's concept of internal working models acts as a bridge between psychoanalysis, which conceives of an internal world populated with objects and their relationships, and cognitive science, which acknowledges internal models of the world
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in the form of mental representations. Psychoanalysis is concerned with affect-laden sensations which act as a distorting prism as we confront the world; cognitive therapy, with the perceptions and constructions which we put on those sensations and erroneous assumptions which follow from them. Psychoanalysis aims to make the unconscious conscious; cognitive therapy starts from conscious thoughts but then reveals the unexamined assumptions that underlie them. Bowlby provides a bridging language between the two approaches. He sees the neurotic patient as basing his relationship to the world on outdated assumptions; for example, that he will be ignored or let down by people, or that his feelings will be dismissed or ridiculed. While these are, in his view, fairly accurate reflections of the way the person has been treated as a child, they do not necessarily bear any relation to current reality, and can lead to poor adaptation in the form of avoidant or ambivalent relationships.
Two factors are at work in maintaining these outmoded models. The first is defensive exclusion of painful emotions which can be overcome by the kind of affective processing advocated in the previous section. The second, related, phenomenon is the need to preserve meaning and to order incoming information from the environment in some kind of schema, however inappropriate.
Liotti (1987; Bowlby 1985) sees these schemata as 'superconscious' (rather than unconscious) organising principles 'which govern the conscious processes without appearing in them', rather as computer programmes determine what appears on the VDU screen without themselves being apparent. An important part of the task of therapy, whether cognitive or psychoanalytic, is to elicit and modify these overarching mental schemata. Given that the patient is likely to become closely attached to the therapist, it is assumed that his assumptions, preconceptions and beliefs will be brought into play in relation to the therapist, and the therapist will re-present them, as they become visible, for mutual consideration. This is Bowlby's version of the phenomenon of transference.
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Always too considerate
Rose was in her fifties when she asked for help after splitting up with her second husband. She felt panicky and depressed and did not see how she could cope with being on her own. She had broken the marriage when she suddenly realised how she was compulsively deferential to her husband, and one more unreasonable request from him was the final straw.
As a child her life had changed dramatically when, at the age of seven, her father had walked out. She had been his favourite and every morning had sat on his lap while he fed her titbits. Now he had a new wife and family and she was relegated to occasional weekend visits where she slept in a cold and undecorated room, surrounded, as she saw it, by inaccessible luxury. At the same time her mother became profoundly depressed and developed an hysterical paralysis. When she recovered she had numerous boyfriends, one of whom she eventually married, and who resented Rose and her sisters' presence and insisted they went to bed at five o'clock every evening. Rose soon learned to suppress her own needs and disappointments and discovered in her teens that charm, good looks and compliance were a heady brew and she was able to attract powerful and successful men.
In her early psychotherapy sessions she announced that the last thing she wanted was any long-term commitment, merely a few sessions to 'sort her out'. She was grateful and dutifully took up any tentative suggestion from the therapist - that she might look at her dreams, or anger - with apparent enthusiasm. As the final scheduled session drew near she looked sad and tentative, but insisted that she was 'fine' and that everything was now going well. When challenged, however, she admitted that she did feel nervous about the end of therapy and really wanted to go on, but had 'assumed' that the therapist was far too busy to be bothered with her for more than a few meetings. In this example of ambivalent attachment she had reproduced with the therapist the very pattern of suppression of need, compliance and role reversal (she looking after the therapist) that characterised her relationship with her mother. She carried over into therapy the cognitive assumption 'I will only be loved if I look after others and please them'. This had served her well as an organiser of experience and a way of avoiding painful
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disappointment and frightening rage, but also acted as a barrier to her achieving what she really wanted and deprived her of feelings of intimacy and ease.
5 COMPANIONABLE INTERACTION
Attachment Theory sees exploratory and attachment behaviour as reciprocal behavioural systems. The securely attached infant feels safe to explore the environment; if danger threatens, exploration is abandoned in favour of proximity-seeking to an attachment figure. In adults, attachment can be differentiated from affiliation (Weiss 1982; Sheldon and West 1989). Affiliative relationships are typically with friends, best 'mates' (an interesting non-sexual use of the term) and comrades and are usually based on mutual exploration of shared interests. Attachment relationships, unlike affiliation, typically provide protection from danger, including the dangers of painful feelings. Thus, as we shall discuss further in the next chapter, Brown and Harris (1978) found that women experiencing loss who had a close confiding relationship with a spouse were protected from depression, while single mothers, even if they had close affiliative-type friendships, were not.
The relevance of this to psychotherapy lies in the likelihood that Heard and Lake's (1986) companionable interaction - synonymous with affiliation - is likely to be a feature of the psychotherapeutic relationship, although it is rarely considered as such by theorists. Freud's early 'training analyses' consisted of a few walks around the Wienerwald (Roazen 1976). A friendship bond undoubtedly does develop in some psychotherapeutic relationships. The tension between the patient's need to see the therapist as a friend, and the professional parameters of the relationship may provide useful transferential material.
Contrasting opening moves
Sarah and Peter, described earlier in the chapter, provide good examples of this point. Sarah would start each session in a bright and breezy way, referring to the weather or to current events as she entered the consulting room. The therapist instinctively did not respond in kind - in a way that would, from the point of view of affiliation, seem almost rude. It was clear from her history
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that she had always managed to avoid intimacy through group living, and by making sure she was the 'life-and-soul' in any gathering, but always keeping her real self well hidden. Her problem was with one-to-one attachments, not affiliation.
Peter similarly would start his sessions with talk about current politics or sport, but in his case the therapist was prepared to join in, in a limited way, again without this being a thought-out strategy. Eventually, when this was discussed in therapy, what emerged was his desperate need to be liked, and his fear of being an outsider, an emotional orphan whom everyone ignored.
In Sarah's case the therapist was adjusting the therapeutic space so that she could get far enough from him to look at what was going on between them; in Peter's he was encouraging him to affiliate enough for some therapeutic interaction to begin.
In most therapies there is an interplay between attachment and affiliation - which might in different terminology be seen as the interplay between transference and the working alliance. The sensitive therapist, like the good-enough parent, is always alert to the patient's need for security in the face of painful affect on the one hand, and, on the other, their wish to explore in a playful, humorous or companionable way.
The issue of affiliation is even more evident in group and family therapies. Affiliation to group members helps demoralised patients feel that they are of some value and importance, and to overcome isolation. Attachment in group therapy is to the group 'matrix' (derived from the word for mother) that holds its members securely and allows for exploration and affective processing. The family group is an affiliative as well as an attachment system, and much of the effort of systemic therapists is directed towards encouraging family members to do more things together and have more fun (while retaining their individuality and separateness). This chapter concludes, therefore, with a brief consideration of Bowlby's contribution to family therapy.
BOWLBY AND FAMILY THERAPY
In all his vast output Bowlby only published one purely clinical - as opposed to theoretical or research - paper. This was 'The study and reduction of group tensions in the family' (Bowlby 1949a). In it he describes his treatment at the Tavistock Clinic of a disturbed young adolescent boy who was destructive and difficult
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and failing to reach his potential at school. After two years of individual therapy Bowlby felt he had reached an impasse: there was no improvement, and the boy was becoming increasingly resistant to the therapy. In desperation he took the innovative step of arranging a joint meeting with the boy and his parents, together with a social worker. The meeting lasted two hours. The first hour consisted of a painful reiteration by the parents of their frustrations and disappointments with the boy. Bowlby countered this by suggesting that their nagging had contributed to his behaviour, but suggested that this had to be understood in the context of their own unhappy childhoods:
After 90 minutes the atmosphere changed very greatly and all three were beginning to have sympathy for the situation of the others . . . they found themselves co-operating in an honest endeavour to find new techniques for living together, each realising that there was a common need to do so and that the ways they had set about it in the past had defeated their object. This proved the turning point in the case.
(Bowlby 1949a)
One senses that here at last Bowlby was allowing himself free rein to do what he really wanted, a process which began in the 1930s when he first began to chafe at the Kleinian bit. Based on Bion's ideas about group therapy he conceptualised the processes involved in family therapy as analogous to individual therapy in which the warring parts of the personality are enabled to communicate more freely with one another and to reach compromise and accommodation. The social optimism of the period (with perhaps also a nod towards Bowlby's surgeon father) is contained within his remark that, once painful and angry feelings are openly expressed,
the recognition of the basic fact that people really do want to live happily together and that this drive is working for us gives confidence, much as a knowledge of the miraculous healing powers of the body gives confidence to the surgeon.
(Bowlby 1949a)
The paper ends with a section entitled 'Circular reactions in family and other social groups', which is thoroughly systemic in its outlook. Bowlby points out the vicious circles of neurosis in which
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'insecure parents create insecure children, who grow up to create an insecure society which in its turn creates more insecure parents', and contrasts this with the virtuous circles of health and the need for 'one great therapeutic endeavour: that of reducing tensions and of fostering understanding co-operation between groups of human beings'.
Although Bowlby did not specifically return to family therapy as a topic after this, he must be credited with having introduced the technique of seeing families together at the Tavistock Clinic, and therefore, alongside Gregory Bateson's Palo Alto group (Bateson 1973), with being the originator of family and systemic therapy which was to become such an important therapeutic mode over the ensuing decades.
Bowlby's ideas have been developed in Britain particularly by John Byng-Hall (1991c), Dorothy Heard (1982) and Robin Skynner (1976). Byng-Hall has addressed the spatial aspect of attachment, which can be illustrated by Schopenhauer's porcupine metaphor as an image for 'too near-too far' dilemmas within families:
A number of porcupines huddled together for warmth on a cold day in winter; but, as they began to prick one another with their quills, they were obliged to disperse. However the cold drove them together again, when just the same thing happened. At last, after many turns of huddling and dispersing, they discovered that they would be best off by remaining at little distance from one another.
(Quoted in Melges and Swartz 1989)
Byng-Hall (1991a), from a child psychiatry perspective, sees the symptomatic patient in a dysfunctional family behaving like the buffer zone between parental porcupines: when the parents start to drift apart the child will develop symptoms which bring them together, and if they start to get dangerously close he will insinuate himself between them, thereby alleviating the imagined dangers of intimacy. Byng-Hall (1985) sees the presuppositions and assumptions which partners bring from their 'families of origin' into their 'families of procreation' in terms of 'family scripts'; namely, patterns of interaction or 'dance' (Minuchin 1974), which an individual expects of himself and those close to him. The distinction made by Minuchin et al. (1978) between enmeshed
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and disengaged families (the former tending to occur in anorexia, the latter in behaviour disorders), can be equated in Attachment Theory terms with ambivalent and avoidant insecure attachment based on the parents' experiences as children and now reproduced with their own offspring.
Perhaps as a counter-balance to Bowlby and Winnicott's emphasis on mothers, Skynner (1976) highlights the role of the father in family attachment patterns. In the early stages of infancy the father's job is to protect the mother-child dyad, to allow attachment to develop and for the mother's 'primary maternal preoccupation' (Winnicott 1965) to flower. Later, he needs to intrude on the intimacy of mother and child, partly in order to make his own relationship with the child and to promote attachment to himself, but also to encourage the process of healthy separation from the mother. The child needs to be able to go off with the father, knowing that he can return to the secure base of the mother when he needs to. Without this Oedipal paternal function the mother will be more likely actively to reject the child, using threats of sending him away or even suicide, which Bowlby sees as a particularly dangerous breeding ground for insecure attachment.
The family therapy perspective shows how attachment patterns perpetuate themselves through the life cycle, event scripts being the psychological equivalent of the genome, or, in Dawkins' (1977) neologism, the 'meme'. The basic aims of psychotherapy - the need to provide a secure base, to help people express and come to terms with anger and disappointment (both of which can be seen in terms of separation protest), to achieve integration and coherence within themselves and their families - represent an attempt to intervene in this cycle, altering not so much an individual personality as a pattern of relating so that good experiences lead, by benign rather than vicious circles, to yet more good experiences, and so on. In this way a healthy social mutation will have occurred and Bowlby's vision of psychotherapy as preventive medicine will, to some degree at least, have been realised.
Chapter 9
Attachment Theory and psychiatric disorder
Many of the most intense of all human emotions arise during the formation, the maintenance, the disruption and the renewal of affectional bonds . . . in terms of subjective experience, the formation of a bond is described as falling in love, maintaining a bond as loving someone and losing a partner as grieving over someone. Similarly, threat of loss arouses anxiety and actual loss causes sorrow; whilst both situations are likely to arouse anger. Finally the unchallenged maintenance of a bond is experienced as a source of security, and the renewal of a bond as a source of joy.
(Bowlby 1979c)
Social psychiatry is concerned with the ways in which the environment influences the origin, course and outcome of psychiatric disorders. In his last, and one of his greatest papers, 'Developmental psychiatry comes of age', Bowlby (1988c) bemoans the 'kidnapping' of the label 'biological psychiatry' by those concerned with biochemical and genetic factors in mental illness. Theories of psychological development, if based on sound ethological and evolutionary principles, are no less 'biological' than is research in neurotransmitter chemistry. As the quotation above implies, a key feature of Attachment Theory is its attempt to combine the psychological and subjective with the biological and the objective. In Chapter 3 we suggested that psychotherapy could be seen as a branch of social psychiatry. The integration of psychodynamic ideas into psychiatry has always been bedevilled by the difficulty in translating the language of the inner world into the quantifiable terms of scientific psychiatry. The aim of
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this chapter is to explore the meeting points between social psychiatry research and the recent developments in Attachment Theory discussed in Chapter 6. Out of this encounter there is beginning to emerge the possibility of a more psychologically meaningful psychiatry, and a more scientifically based psychotherapy.
Bowlby compares the role of Attachment Theory in psychiatry with that of immunology in medicine. The comparison is apt, not just because both are concerned with the integrity and security of the individual, but also because immunology, as well as being concerned with specific disorders of the immune system, has a contribution to make to the understanding of a wide variety of medical conditions. Similarly, Attachment Theory has its 'own' disorders to which it is particularly applicable - abnormal grief, neurotic depression, agoraphobia - but can also inform many other aspects of social psychiatry.
Psychoanalytic theorising about the relationship between childhood experience and psychiatric illness - for example, Freud's linking of repressed homosexuality and paranoia - or even more recent speculations about childhood 'theories of mind' (Fonagy 1991) and borderline personality disorder have found disfavour in psychiatric circles for two main reasons. First, psychiatrists tend to use much more tightly defined categories of mental illness than do psychotherapists, for whom, for example, a term such as 'psychotic' is often used in an overinclusive and arcane way. Second, it is very difficult to specify the presence or absence of a category such as 'repressed homosexuality' in a way that lends itself to research. Bowlby's strategy for getting round these difficulties was to concentrate on external, uncontroversial events such as separations. But here too the attempt to relate adult psychological disorder to single events such as childhood separation has been found to be an oversimplification. Apart perhaps from post-traumatic stress disorders there is no one-to- one link between environmental trauma and psychiatric illness. Indeed, given the complexity of psychological development, the variety of experience, and fluidity of meanings by which experience is comprehended, it would be surprising if this were so. A more subtle, if less attractively simple, model of stress, vulnerability and buffering is required.
Attachment Theory is a theory about relationships, based on the idea that human beings evolved in kinship groups and that in
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the original 'environment of evolutionary adaptedness' (Bowlby 1969b) survival was increased by the maintenance of secure bonds between their members, primarily, but by no means exclusively, between parents and children. The theory, fundamental to social psychiatry, suggests that relationships and their difficulties might influence psychiatric disorder in three distinct but interrelated ways. First, the breaking or disruption of bonds is likely in itself to be a cause of disturbance. Second, the internalisation of disturbed early attachment patterns may influence subsequent relationships in a way that makes a person both more exposed and more vulnerable to stress. Third, a person's current perception of their relationships and the use they make of them may make them more or less vulnerable to breakdown in the face of adversity. We shall briefly consider each of these points, and then proceed to discuss a number of selected psychiatric disorders in the light of them.
Loss
There is strong evidence of the relationship between acute loss and increased vulnerability to psychiatric and physical disorder. Widows and widowers are more likely than non-bereaved people to die themselves from a coronary in the year following the sudden death of their partners from a heart attack. Among depressed patients 60-70 per cent have had an unpleasant loss event (usually involving the loss of or threat to an attachment relationship) in the year preceding their illness, as opposed to only 20 per cent of non-depressed controls. Schizophrenic relapse is often brought on by loss or unexpected change. People who commit suicide or attempt suicide are similarly more likely to have experienced loss than those who do not.
However, as we discussed in Chapter 3, for loss to be pathogenic it has to be in the context of other important variables. Not all those who experience bereavement succumb to depression. Those for whom the loss was sudden and untimely, who had a dependent relationship with the person they have lost, or felt ambivalent towards them, and who lack a supportive relationship and network of friends, are much more vulnerable.
A similar story appears to hold for the long-term effects of childhood loss. Early speculation suggested that childhood bereavement was an important factor in adult depression. While
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recent research on this point has been contradictory (Tennant 1988: Harris and Bifulco 1991), it does seem clear that the lack of good care that is so often a result of childhood bereavement is a vulnerability factor for depression, and that there are important additive effects, so that loss in adult life, in the presence of vulnerabilities in the personality, makes a person much more likely to become depressed than in their absence.
Attachment styles and vulnerability to psychiatric disorder
We presented in Chapter 6 the evidence that infant attachment patterns persist well into middle childhood, and the Adult Attachment Interview (AAI) data suggest a further continuity of these patterns into adult life. This means, in Western countries at least, that about one-third of adults are likely to have relationships which are characterised by anxious attachment, and this could constitute a major vulnerability factor for psychiatric illness when faced with stressful life events. Using postal questionnaires, Shaver and Hazan (1988; Hazan and Shaver 1987) surveyed a college freshman population and a middle-aged sample about 'romantic attachments' and found remarkable parallels with the Bowlby- Ainsworth classification of infant attachment in the Strange Situation. Of their respondents 56 per cent demonstrated a secure attachment pattern, describing themselves as finding it relatively easy to get close to others, to depend on them, and not worrying about being abandoned or about being intruded upon. Twenty- five per cent showed an avoidant pattern, with difficulty in trusting their partners, and often feeling that their partners wanted more intimacy than they felt able to provide. The remainder (19 per cent) were anxious-ambivalent, often worrying that their partners didn't really love them, and aware that their great neediness and possessiveness often drove potential partners away.
Attachment research on children has shown correlations between attachment styles and social competence. Similar connections can be demonstrated in college students (Kobak and Sceery 1988): those classified as secure on the AAI were rated by their peers as more ego-resilient, less anxious and hostile, and as having greater social support than the anxious-dismissives and anxious-preoccupieds who were less resilient, less supported and more hostile or anxious respectively.
Lake (1985) has pointed to the discrepancy between the
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frequent invocation of the notion of ego-strength as a mark of mental health, and the lack of a satisfactory definition and operational criteria for its presence. For him ego-strength comprises the ability to form mutually satisfying intimate relationships, the capacity to cope with change, good self-esteem, and a sense of competence. In a similar vein, Holmes and Lindley (1989) define 'emotional autonomy' as the key to mental health and a central goal of psychotherapy:
Autonomy, in the context of psychotherapy, implies taking control of one's own life . . . emotional autonomy does not mean isolation or avoidance of dependency.