No More Learning

She needed to be held by the hospital ward - sometimes actually - before she could begin to think about holding herself in mind in therapy, and to feel secure about her capacity to be a mother to her daughter. As suggested by Figure 6. 2, her mental state could be represented by a series of parallel concentric circles of holder and held.
Borderline patients like this provide adult examples of the insecure infant with a deficient holding environment, whose mother has been unable to reflect on and so metabolise her infant's feelings of pain on separation, who survives as best she can, using splitting, isolation and self-harm as ways of coping, and who, when she becomes a parent, is in great danger of perpetuating the cycle of insecurity. Ward staff and therapists may then counter- transferentially re-enact a repetition of the unresponsiveness and breaks in care that the patient experienced as a child. Thus Anna became passionately involved with one male nurse - paralleling her long-repressed desire to have an exclusive relationship with her mother - and did very well until he was transferred to another ward, whereupon she took a huge overdose of drugs.
Bowlby depicted healthy internal working models as subject to constant revision and change in the light of experience. Anna exemplified how in pathological mental states there is often a sense of repetitiousness and stuckness in therapy. Bretherton (1987) has speculated about why it might be that internal working models in insecure attachment are particularly resistant to change. She sees mental structures as organised hierarchically from low-level 'event-scripts' (Shank 1982), such as 'When I hurt myself my mother comes to comfort me', through intermediate generalisations like 'My mother is usually there when I need her', to basic assumptions: 'My mother is a loving person. I am lovable and loved. ' Insecure individuals not only may have negative core assumptions, but because communication between different levels of the hierarchy is distorted and restricted, may not be able to revise these models in the light of experience. Anna's basic assumption - 'I am hateful' - remained impervious to contrary evidence provided by the love of her boyfriend and the care of her therapists:
Figure 6. 2 Anna and the holding environment
122 Attachment Theory
What seems to differentiate the Internal Working Models of secure and insecure individuals is in part their content, but also their internal organisation and relative consistency within and across hierarchical levels. . . . Reconstruction of working models cannot be achieved [simply] by 'lifting repression' or removing barriers which allow well-encoded, but hitherto inaccessible information to come into conscious awareness. Something much more akin to complete reorganisation and reinterpretation may be necessary.
(Bretherton 1991a)
THERAPEUTIC IMPLICATIONS
From the perspective of Attachment Theory the process of therapy will require the provision of a secure base, comprising reliability, responsiveness and the capacity to process negative affect, especially in relation to separation and loss. Out of this should emerge an individual with a greater capacity for self-reflection, increased coherence of mental structures and enhanced autobiographical competence. The implications of this for psychotherapy with adults will be considered in the next two chapters. It is beyond the scope of this book to consider the full implications of Attachment Theory for psychotherapy with children, and the reader's attention is drawn to the considerable literature on the subject (Belsky and Nezworski 1988; Greenberg et al. 1988). Three important areas of work will briefly be mentioned.
Lieberman and Paul (1988) have shown that a clinical classification of neurotic disturbance in pre-school children fits well with the categories suggested by Attachment Theory research. They found three basic groups of problematic behaviours: excessive danger seeking, such as wandering off unaccompanied in children whose mothers appeared to discount the attachment needs of their offspring; excessive danger fleeing with punitive mothers who discouraged exploration and illustrated the paradox of clinging to a punitive attachment figure; and children who were 'hypercompetent', equivalent to Bowlby's category of 'compulsive caregiving' (Bowlby 1980) in which there was role- reversal between children and their mothers and inhibition of expression of painful affect.
Attachment Theory and personality development 123
Informed by attachment theory, several groups have attempted preventive psychotherapy with depressed mothers by working directly with the mother and her infant. Murray and Cooper (1992) describe one such case.
'Uppie . . . uppie'
Following a puerperal depression, Joan had felt unable to get emotionally close to her 18-month-old daughter Sophie, and was frightened that the pattern of distance and lack of trust which characterised her relationship with her own mother was repeating itself. Tested on the Strange Situation, Sophie showed a typical pattern of insecure-avoidance. In the course of brief exploratory- supportive therapy in which Sophie and Joan were seen together, their relationship changed dramatically. In place of distant watchfulness, Sophie began to approach her mother, asking to be picked up and cuddled, saying 'Uppie, uppie', and was responded to with warmth and affection. At the same time negative feelings became less problematic for both of them. When Sophie cried or was difficult and rejecting, Joan could tolerate this without feeling guilty, and could also allow herself to become irritable with her daughter at times. In parallel with these changes Joan reported an improvement in her relationship with her own mother: here too she could be both affectionate and cross instead of, as before, maintaining a cool distance. At termination, Sophie's re-test on the Strange Situation now showed a pattern of secure attachment. In place of a rigid and restricted pattern of relating, each was able to respond to the other in a more fluid and spontaneous way. This movement from inflexibility towards 'give' and play illustrates Winnicott's (1965) well-known dictum that the essence of psychotherapy is learning to play.
In view of the increasing numbers of adult psychotherapy patients who report sexual and/or physical abuse in childhood, mention must also be made of studies which have approached familial abuse from the perspective of Attachment Theory. 'High risk' (that is, low socio-economic status) parents do not have disproportionate numbers of insecure children. The A/B/C ratios remain roughly the same: B, 65 per cent; A, 20 per cent; C, 15 per cent. The proportion of A/C families rises sharply among mothers with major depressive illness, and in families where there is proven sexual or physical abuse. With depressed mothers, 40 per cent of
124 Attachment Theory
children were insecure-avoidant, and in abusive families 50 per cent are avoidant and 30 per cent disorganised, with only 10 per cent classified as secure (Belsky and Nezworsky 1988). The apparent compliance and conformity sometimes seen in adult patients who have been abused can be understood in the light of Crittenden's (1988) comment that
Attachment Theory proposed that the maintenance of affectional bonds . . . is essential to the survival of the human species and a compelling individual need. . . . Those people who are most at risk for destroying their love relationships altogether devote the most intense effort towards maintaining the semblance of bonds; inept mothers and their children scrap and feud; mildly abusing mothers and their children are hostile and difficult; but many severely maltreating mothers do not dare challenge the durability of their relationships . . . it is as though they fear that a simple dispute could become an uncontrollable attack on the relationship.
CONCLUSION
Bowlby's grafting of the experimental methods of ethology to the insight of psychoanalysis has born rich fruit. The research we have surveyed in this chapter has begun to lay bare some of the relational elements which provide the foundations of psychological health: a sense of security, of efficacy, of being loved and having the capacity to love, of being a person in the world like others and yet with one's own unique biographical trajectory, of being able to withstand the failures, losses and disappointments that are the inevitable consequence of the 'thousand natural shocks that flesh is heir to'. We have learned about some of the ingredients that make up good parenting: responsiveness, attunement, holding. We turn now to the implications of these findings for psychotherapy, and to further exploration of the relationship - at times avoidant, at times ambivalent - between Attachment Theory and psychoanalysis, in the hope of finding a more secure and coherent synthesis.
Part III Implications
Chapter 7
Bowlby and the inner world: Attachment Theory and psychoanalysis
[The] early formulations of psychoanalytic theory were strongly influenced by the physiology of the day . . . cast in terms of the individual organism, its energies and drives, with only marginal reference to relationships. Yet, by contrast, the principal feature of the innovative technique for treating patients that Freud introduced is to focus attention on the relationships patients make with their therapist. From the start, therefore, there was a yawning gulf between the phenomena with which the therapist was confronted, and the theory that had been advanced to account for them.
(Bowlby 1990)
Bowlby was primarily a theorist rather than a therapist. Although trained psychoanalytically, and active in the Psycho-Analytical Society from the late 1930s until the late 1950s, where he held high office, he saw himself mainly as a researcher and administrator. Case reports and clinical illustrations are to be found throughout his writings, but, with the exception of his earliest papers, these are almost all based on the work of colleagues or on published articles by other authors. Dreams are nowhere to be found in his work, and he is, for the most part, concerned with observable behaviour rather than the inner world. Nevertheless, Attachment Theory is a child of psychoanalysis and has much to contribute to the theory and practice of psychotherapy. Towards the end of his career Bowlby (1991)
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wrote, 'my theoretical work has always been directed primarily to my colleagues in the International [Psychoanalytical] Association'. The aim of this chapter is to consider in some detail the relationship between Attachment Theory, psychoanalysis and contemporary psychoanalytic psychotherapy.
Bowlby's reservations about psychoanalysis come under four main headings: its neglect of real experience and environmental influence in favour of overemphasis on autonomous phantasy; an atmosphere of dogmatism inimical to scientific enquiry; an outmoded metapsychology; and a lack of experimental observation to underpin its unbridled theorising. All of these objections may seem to the contemporary observer somewhat overstated, and we must first place them in an historical context.
HISTORY: BRITISH PSYCHOANALYSIS 1935-60
The atmosphere in the British Psycho-Analytical Society when Bowlby started training in the mid-1930s was one of ferment and controversy. The heady excitement of a new science of mind that went straight to the heart of twentieth century men's and women's discontents seemed to have generated a hotbed of intrigue, back-biting, gossip and jockeying for position. The climate resembled less that of a scientific society than of a family in which a patriarch was nearing the end of his life with the terms of his inheritance still undecided.
Ernest Jones had invited Melanie Klein to practise in London and had entrusted his own two children to her for child analysis based on her new technique of play therapy. Until the advent of Klein, the focus of analytical work was predominantly the Oedipus complex. She insisted on the importance and the analysability of much earlier stages of development, and in particular on the phantasies and anxieties of the infant in its first two years of life. As we saw in Chapter 1, Freud tended to regard Klein's views with some disfavour (Steiner 1985), especially as her ideas about child analysis differed from those of his daughter Anna, who saw splitting and other primitive defence mechanisms such as projective identification proposed by Klein as belonging to a much later stage of development.
At the time of the arrival of Freud and Anna in London in the late 1930s the British Society comprised a group of highly talented and intelligent people, including James Strachey, Edward Glover, Sylvia Payne, Melanie Klein (Bowlby's supervisor) and Joan Riviere (Bowlby's analyst). A leadership struggle broke out with
Bowlby and the inner world 129
an increasing schism between the Kleinian camp, who were accused of dogmatism and attempts to win students exclusively onto their side, and the more orthodox Freudians, represented by Anna and her followers, together with a third group, who remained non-aligned. Eventually, in 1944, a compromise was reached with the 'gentleman's agreement' (in fact made between three women, Klein, Payne and Anna Freud) between the parties to form separate 'streams' of training and scientific discussion, while remaining united within one society.
Although Bowlby's organisational and intellectual talents were recognised early on - he was appointed Training Secretary of the Society in 1944 (Melanie Klein opposed this on the grounds that he was not a Training Analyst) - he was somewhat at variance with the mainstream of the analytic milieu. His strong commitment to the scientific method, his quintessential Britishness and reserve, his decision to work in child guidance clinics rather than in private practice, set him apart. These very qualities, as well as the fact that he was the son of a famous surgeon, may also have given him the credibility with the medical establishment that was needed for his successful popularisation of psychoanalytic ideas about the importance of infancy, and the mother-child relationship, as a determinant of later mental health.
From early in his psychoanalytic career Bowlby had had misgivings about the way in which analysts downplayed the importance of the environment in the origins of psychological disturbance. Although Freud has been accused of a deliberate and cowardly retreat from his original hypotheses about the adverse effects of childhood seduction (Masson 1985), there is no doubt that he continued to believe that childhood trauma was important, but as the pioneer of a new 'science' he emphasised the primacy of the inner world as the proper domain of psychoanalytic discourse, and this lead was certainly adhered to by his followers. Bowlby writes:
During . . . 1936-39 I was slowly waking up to the fact that my ideas were developing in a direction very different from those that were accepted truths in the British Psycho-Analytical Society . . . under the influence of Ernest Jones and Melanie Klein it was held that an analyst should concern himself only with the patient's internal world and that to give attention to his real life experiences could only divert attention from what really matters. My experiences in the Child Guidance Clinic . .
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. were leading me to an opposite conclusion . . . that one can only understand a person's internal world if one can see how [it] has come to be constructed from the real-life events to which he has been exposed.
(Bowlby 1991; Rayner 1992)
A marked copy of a paper by Bowlby's analyst Joan Riviere contains the following passage:
Psychoanalysis is Freud's discovery of what goes on in the imagination . . . it has no concern with anything else, it is not concerned with the real world . . . it is concerned simply and solely with the imaginings of the childish mind.
(Quoted in Rayner 1992)
In the margin Bowlby has pencilled 'Role of the environment = zero' (Rayner 1992). Bowlby was particularly distressed when the mother of his first training patient in child analysis, a hyperactive little boy of three, was admitted to mental hospital:
When I reported this to Melanie Klein [his supervisor], however, her only concern seemed to be that, since it was no longer possible for me to continue the boy's analysis, another patient must be found for me. The probability that the boy's behaviour was a reaction to the way his mother treated him seemed altogether to escape her.
(Bowlby 1991)
Bowlby consistently stressed the range of environmental traumata to which a developing child can be exposed: actual separations and disruptions in care; threats of separation or suicide by parents; being unwanted, or the 'wrong' sex; suppression of the true facts about parentage (for example, grandfather or uncle the true father, or sister the true mother); role reversal and the 'parentification' of children. His views have been thoroughly vindicated by the recent disclosure of the extent of physical and sexual abuse of children. The evidence that more subtle forms of environmental failure such as parental unresponsiveness and mis-attunement underlie childhood and probably adult psychopathology has been reviewed in the previous chapter. These findings make the polarisation between Bowlby's characterisation of the Kleinians as wholly uninterested in the environment and exclusively concerned with phantasy, and his own insistence on the primacy of
Bowlby and the inner world 131
environmental failure rather artificial. The Kleinian account is a phenomenological description of mental states found in adult patients, particularly those with borderline pathology, inferring from these what may have gone on in the minds of infants and small children. The Kleinian account contains no clear causal model to account for the phenomena she describes. Bowlby and the post-Bowlbians offer the outlines of an explanation of how such pathological states come about. They suggest that the capacity to phantasise and to symbolise, as opposed to resorting to defensive enactments of unmanageable feelings, is itself environmentally sensitive. Parents who can contain and attune to their children have children who can put their feelings into words and who are able to resolve conflict. Those who cannot contain and attune are more likely to have children who are at risk of dealing with their feelings by splitting and projective identification, and so being afflicted by a sense of emptiness and meaninglessness. It is worth noting that Klein, like Freud, assumes that there may be constitutional differences between infants, a point which Bowlby tends to overlook. Westen (1990) has suggested that some babies may have reduced inborn capacities for self- soothing, which would make them more vulnerable to parental deficiencies in containing and calming.
A second area of difficulty about psychoanalysis for Bowlby was its atmosphere of dogmatism and authoritarianism. Peterfreund (1983), who is approvingly cited by Bowlby in several places, decries what he calls the 'stereotyped', dogmatic, 'alogarithmic' approach of traditional psychoanalytic formulation and interpretation. He compares this with the 'heuristic' approach which he and Bowlby advocate, in which patient and therapist find things out for themselves rather than imitating Talmudic scholars burrowing in the obscure texts of the psychoanalytic testament. There is no doubt that at its worst psychoanalysis can degenerate into a mouthing of cliche? d formulas by an omniscient analyst who, faced with the pain and complexity of suffering, offers some certainty, however ill-founded, to a confused patient who has no choice but to grasp at straws. The relentless interpretation of the transference may hypnotically open the patient up to layers of regression and dependency which make such interpretations self-fulfilling prophecies. There has been a move towards a much more tentative approach to interpretation in contemporary psychoanalysis (Casement 1985), in which Keats's 'negative capability' - the capacity to allow oneself to be 'in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason' - is valued, and indeed is seen as the hallmark of the 'depressive position' with its emphasis on compromise and reconciliation
132 Imlications
rather than splitting and false certainties. Bowlby writes that
I was dissatisfied with much of the [psychoanalytic] theory . . . being a somewhat arrogant young man . . . I was in no mood to accept dogmatic teaching. My analyst was not altogether happy with my critical attitude and complained on one occasion that I would take nothing on trust and was trying to think everything out from scratch, which I was certainly committed to doing.
(Bowlby 1991)
Bowlby's re-thinking of psychoanalytic metapsychology and terminology has been discussed in the preceding three chapters. Attachment Theory is perhaps best seen as a variant of Object-Relations Theory, using updated terminology and informed by neo-Darwinism. Attachment comprises a distinct motivational system - which includes drive, affect, cognition and behaviour - that parallels and complements sexuality. The main differences between classical Freudian theory, the Object-Relations Theory of Klein, Fairbairn and Winnicott, and Attachment Theory are summarised in Table 7. 1. For Bowlby the important issue is not, as the orthodox Freudians thought, sex, but security. Attachment is primary, not a derivative of orality. The organism is not an isolated drive-driven creature in search of an object on whom to discharge his accumulated tension, but a person relating to other persons. Homeostatic and other cybernetic control systems govern his behaviour, just as they do that of other mammals. His relationship to the world is determined not just by unconscious phantasy but also by internal working models which include affective, cognitive and behavioural elements. Aggression is a response to frustration and loss, not an intrinsic property of an individual dominated by the death instinct.
Bowlby's fourth cavil at psychoanalysis was its neglect of direct observation of normal and abnormal children. He felt that reconstructions based on childhood recollections of disturbed patients, while valuable in themselves, did not qualify as a scientific account of what really goes on in real children. He therefore set out to study systematically the effects of separating infants and
Table 7. 1 Classical, Object-Relations and Attachment Theories compared


136 Imlications
children from their parents, and it was on the basis of those findings that Attachment Theory was born.
BOWLBY AND THE POST-FREUDIANS: THE POST-WAR PERIOD
To continue with our historical account, Bowlby was of course not alone in his dissatisfaction with the state of psychoanalysis in the 1940s and early fifties. During the post-war period several divergent responses can be found within psychoanalysis and psychotherapy in response to the difficulties - dogmatism, obsolete metapsychology and anti- empiricism - with which Bowlby was struggling. The first was the development of Object-Relations Theory, epitomised by the work of Winnicott, Fairbairn and Balint, all of whom were influenced by the Kleinian emphasis on the early infant- mother relationship, but, taking the decisive step of abandoning drive theory altogether, posited relationships as primary. Mahler's (1975) direct observations of mothers and infants from a psychoanalytic perspective combined object relations with a degree of empiricism.
A quite different tack was to reject the pseudo-scientific determinism of classical Freudianism altogether, seeing psychoanalysis more as a hermeneutic discipline concerned with meanings rather than mechanisms and emphasising the importance of the creative imagination and spontaneity as the wellspring of the psychoanalytic process (Rycroft 1985). Meanwhile, neo-Kleinian developments concentrated on delving deeper and deeper into the mysteries of the infant- mother relationship in the early stages of life and relating these to the findings of psychoanalysis with psychotic patients (Bion 1978). Finally, there were moves away from the psychoanalytic paradigm altogether, adopting either a family systems approach derived from cybernetics and anthropology (Bateson 1973), or a 'cognitive' approach, based on Piaget and Kelly, in which the logical operations of the mind and the way in which they are organised hierarchically form the basis of psychotherapeutic theory and practice (Beck et al. 1979).
Bowlby and the inner world 137
Bowlby and Winnicott
Bowlby as a researcher responded to the problems of the psychoanalytic paradigm by moving in the direction of observable behaviour. Attachment, whether secure or insecure, avoidant or ambivalent, can be observed, rated, measured, correlated. By basing his ideas on ethology Bowlby sidestepped the dehumanisation and absurdities of stimulus- response behaviourism, while remaining within the framework of conventional science. Winnicott, an outstanding clinician but an elusive theorist, was wrestling with the same problems but from the perspective of the inner world, developing in his idiosyncratic but highly original way a language of experience directly applicable to the therapeutic situation.
Winnicott and Bowlby had much in common. Both were very 'English' in their background and outlook, in contrast to the European/ Jewish/Celtic atmosphere of the Psycho-Analytical Society. Both had had a Cambridge scientific education and were deeply influenced by Darwin. They shared an analyst, Joan Riviere, who, despite her later Kleinian orthodoxy, was firmly interpersonal in her philosophy. With an echo of John Donne, she wrote:
There is no such thing as a single human being, pure and simple, unmixed with other human beings. Each personality is a world in himself, a company of many. That self . . . is a composite structure . . . formed out of countless never-ending influences and exchanges between ourselves and others. These other persons are in fact therefore part of ourselves . . . we are members of one another.
(Riviere 1927; reprinted 1955)
Winnicott (1965) was therefore paraphrasing Riviere in his famous dictum, 'there is no such thing as an infant . . . wherever one finds an infant one finds maternal care and without maternal care there would be no infant'. Like Bowlby, Winnicott was primarily concerned with the welfare of children, and wrote to an American enquirer about his wartime experiences:
I became involved with the failure of the evacuation scheme and could therefore no longer avoid the subject of the antisocial tendency. Eventually I became interested in the etiology of delinquency and therefore joined up quite naturally with
138 Imlications
John Bowlby who was at that time starting up his work based on the relationship that he observed between delinquency and periods of separation at significant times in the child's early years.
(Rodman 1987)
When Winnicott later was offered the presidency of the PsychoAnalytical Society he accepted, on condition that he have a deputy who would take care of the detailed administrative work. The ever-efficient Bowlby was an obvious choice. They make sparse but polite references to each other's work in their writings. There are many similarities between their theoretical viewpoints, despite the radically different language which each uses. Rycroft's (1985) remark that 'I've always had a phantasy that Bowlby and I were burrowing the same tunnel, but that we started at opposite ends', would be equally true of Bowlby and Winnicott.
Winnicott and Bowlby's responses to the Kleinian domination of the Psycho-Analytical Society can be seen in terms of avoidant and ambivalent attachment. Bowlby, in an avoidant way, distanced himself, expressing neither warmth nor anger, but having little to do with the Society after the 1960s.
Winnicott clung ambivalently to his alma mater, and, in his theory of hate, emphasised how identity can be forged through opposition and reaction.
Bowlby and Winnicott's overall view of the infant-mother relationship, and what may go wrong with it, is very similar. Winnicott postulates a 'holding environment' provided by the mother, in which, on the basis of her 'primary maternal preoccupation', she can empathise with the needs and desires of the growing child. The main job of the holding environment is, like attachment, protection, although, in contrast to Bowlby, Winnicott describes this in existential rather than ethological terms: 'The holding environment . . . has as its main function the reduction to a minimum the impingement to which the infant must react with resultant annihilation of personal being' (Winnicott 1965). Winnicott sees 'handling' and 'general management', equivalent to the Bowlbian concept of maternal responsiveness, as the framework within which need can be met. The mother's actual physical holding and handling are primary:
The main thing is the physical holding and this is the basis of all the more complex aspects of holding and of environmental
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provision in general. . . . The basis for instinctual satisfaction and for object relationships is the handling and general management and care of the infant, which is only too easily taken for granted when all goes well.
(Winnicott 1965)
'Good-enough' holding leads to integration of the infant personality, to a 'continuity of going-on-being', which prefigures Stern's (1985) idea of a 'line of continuity' that is the germ of the sense of coherent self. Where there is such continuity the growing child can cope with temporary separations without resorting to maladaptive defences. Like Bowlby, Winnicott sees the seeds of pathology in failures of the holding environment. Separations may provide the nucleus of later delinquency:
Separation of a one or two year old from the mother produces a state which may appear later as an anti-social tendency. When the child tries to reach back over the gap [i. e. , created by the separation] this is called stealing.
(Winnicott 1965)
Although Bowlby and Winnicott are saying something very similar about juvenile theft there is a subtle difference in their language and focus. For Bowlby theft is a sociological phenomenon, which can be well accounted for by the disrupted lives and maternal separations of the thieves' early childhood. Winnicott is reaching towards an understanding of the symbolism of the act of theft itself. He is suggesting that the stolen object stands in for the missing mother which the youth is using to bridge the emotional gap left by her absence. Bowlby is reaching for explanation, Winnicott for meaning. Both, incidentally, tend to ignore other possible aspects of the problem: Bowlby looks exclusively at the childhood experiences of his thieves, and ignores contemporary influences such as housing and unemployment, while Winnicott leaves little room for the many other possible symbolic meanings that an act of theft might represent.
Winnicott goes on to describe how the good mother empathically understands what stage the child's object constancy has reached and so knows how to handle separations: 'She knows she must not leave her child for more minutes, hours, days than the child is able to keep the idea of her alive and friendly' (Winnicott 1965). If this is unavoidable she will have to resort to
140 Imlications
therapeutic 'spoiling': 'If she knows she must be away too long she will have to change from a mother into a therapist in order to turn the child back into a state in which he takes the mother for granted again' (Winnicott 1965).
Like Winnicott, Bowlby is insistent in his opposition to the notion that children can be 'spoilt' by too much love, and reminds therapists who are working with adults who weep and cling: 'It is perhaps too often forgotten by clinicians that many children when they become distressed and weepy and are looking for comfort are shooed off as intolerable little cry-babies' (Bowlby 1988a).
Winnicott visualises 'two mothers' in the early months of life. The first protects the child from 'impingement' and acts as an 'auxiliary ego' which enables him gradually to build up his own autonomous ego. He calls this the 'environment mother' who offers 'affection and sensuous coexistence'. Within the ambiance created by the environment mother the child then relates to the 'object mother' who can be sucked and bitten, loved and hated. Her response will have far-reaching consequences: overintrusiveness can in a seductive way be as traumatic as neglect, and both can lead to defensive moves such as 'self-holding', disintegration and the development of a false self.
For Bowlby there are also two mothers. The first is equivalent to Winnicott's 'environment mother', the provider of the secure base. The second mother is the companion with whom the child, once a secure base has been established, engages in exploratory play. This 'third mother' is different from Winnicott's second 'object mother' with whom the child engages in orgiastic play. Bowlby seems less interested in orgasmic activities, although the sexual foreplay of trusting adults can be seen as a form of mutual exploration (analogous to the sensuous intimacy of mother and child), which enables a greater build-up of intense pleasure than orgasm not preceded by exploration.
In Winnicott's sophisticated theory of the origins of play he sees the emphatic responsiveness of the mother helping to create a necessary illusion of omnipotence in the infant so that, as a wish begins to form in the child's mind so she begins to answer it - just as the baby begins to feel hungry, the breast appears, as though by magic. In this transitional zone of overlapping phantasy are to be found the origins of playfulness, creativity and, ultimately, culture. Bowlby's 'companion mother' can be seen in similar, if less mystical terms. The post-Bowlbians emphasise the
Bowlby and the inner world 141
collaborative nature of exploration, the 'zone of proximal development' (Vygotsky 1962), where parent and child interact and in which learning takes place. Stern (1985) sees the task of the mother as maintaining an internal 'line of continuity' for the child, so that she will unobtrusively stimulate the child when his imagination begins to flag, back off when he is playing happily, and dampen his excitement when it threatens to get out of hand. The differing languages of Winnicott and Bowlby reflect the differing foci of their thought. For the Bowlbian, child play and exploration take place 'out there' in the world, while Winnicott's child is concerned with inner exploration, with the world of the imagination 'in here'. The real child is of course engaged in both at the same time. The toddler building and breaking and building again his tower of bricks is simultaneously acquiring Piagetian knowledge of physics - the properties of materials, the mathematics of cubes, the nature of gravity - and in a Freudian sense exploring potency and castration, and the interplay of destruction and reparation of the inner world.
Klein's depressive position becomes in Winnicottian terminology the 'stage of concern'. Here the 'environment mother' and the 'object mother' come together as one person. The environment is necessarily defective: the mother cannot always be perfectly responsive: there will be gaps and breaks and discontinuities of care. The child responds with aggression and rage directed at the 'object mother': she survives the attacks and continues to love her child, and the balance is restored. He now realises that the mother who lets him down is also the one he loves. Clouds of guilt and anxiety appear on his horizon, but also the seeds of gratitude and reparation. For Bowlby, too, the good mother can withstand her child's aggressive onslaughts, and these early experiences lead to a mental set in later life (based on internal working models) that feelings can be expressed and 'processed', conflicts successfully resolved. The anxiously attached child is caught up in a vicious circle (see Figure 7. 1) in which he lacks a secure base; feels angry and wants to attack the attachment figure for premature separation; doesn't dare to do so for fear of retaliation or pushing the attachment figure even further away; and so suppresses his feelings of anxiety and rage thereby increasing the sense of insecurity; leading ultimately to an expectation of lack of care, and danger in emotional expression with potentially disastrous implications for self-esteem and intimate relationships. There is, in this 'Winnicott- type theory' (Bowlby 1988b)
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Figure 7. 1 The anxiously attached infant
a massive block against expressing or even feeling a natural desire for a close trusting relationship, for care, comfort and love - which I regard as the subjective manifestations of a major system of instinctive behaviour.
Like Bowlby, Winnicott also repudiates the linear 'monorail' model of development in which the child progresses from oral to anal to genital phases of development:
Most of the processes that start up in early infancy are never fully established and continue to be strengthened by the growth that continues in later childhood and indeed in adult life, even in old age.
(Winnicott 1965)
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Bowlby and Kohut
Bowlby's conviction that attachment needs continue throughout life and are not outgrown has important implications for psychotherapy. It means that the therapist inevitably becomes an important attachment figure for the patient, and that this is not necessarily best seen as a 'regression' to infantile dependence (the developmental 'train' going into reverse), but rather the activation of attachment needs that have been previously suppressed. Heinz Kohut (1977) has based his 'self psychology' on a similar perspective. He describes 'selfobject needs' that continue from infancy throughout life and comprise an individual's need for empathic responsiveness from parents, friends, lovers, spouses (and therapists). This responsiveness brings a sense of aliveness and meaning, security and self-esteem to a person's existence. Its lack leads to narcissistic disturbances of personality characterised by the desperate search for selfobjects - for example, idealisation of the therapist or the development of an erotic transference. When, as they inevitably will, these prove inadequate (as did the original environment), the person responds with 'narcissistic rage' and disappointment, which, in the absence of an adequate 'selfobject' cannot be dealt with in a productive way.
BOWLBY AND CONTEMPORARY PSYCHOTHERAPEUTIC THEORY
There is an inherent dualism in the Freudian project. Freud saw psychoanalysis as a science, and wanted his accounts of psychopathology to have the same status and explanatory power as those of physical medicine. At the same time, as Rycroft (1985) points out, he called his magnum opus The Interpretation, not The Cause of Dreams, and
It can indeed be argued that much of Freud's work was really semantic and that he made a revolutionary discovery in semantics, namely that neurotic symptoms are meaningful, disguised communications, but that, owing to his scientific training and allegiance, he formulated his findings in the conceptual framework of the physical sciences.
(Rycroft 1985)
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The scientific-explanatory and the semantic-hermeneutic poles of Freud's thought are epitomised in contemporary psychotherapy on the one hand by Kleinian and Lacanian psychoanalysis and on the other by cognitive therapy. In this section I shall first give a brief account of these apparently irreconcilable approaches and then suggest that Attachment Theory provides a possible bridge between them.
Rustin (1991) has described the history of psychoanalysis as moving through the three Kantian categories of truth: scientific, ethical and aesthetic. Freud saw himself as a natural scientist, looking for general truths about normal and abnormal psychology; Melanie Klein's theories were essentially ethical - about destructiveness and splitting and the reconciliation of good and bad in the depressive position; Rustin sees current psychoanalysis as predominantly aesthetic in its orientation. Kant distinguishes aesthetic from scientific or moral judgement in having to do with 'disinterested contemplation of objects of experience, related neither to the goal of interpersonal knowledge of causes, nor to issues of conformity with the moral law' (Rustin 1991). The discovery of meanings is central to this aesthetic sensibility, the prototype of which is to be found within the mother-infant relationship. The mother 'contains' or 'binds' (Bion 1978) infantile sense experiences and mental images; she points, and shapes and names, and so gives meaning to them. Maternal attunement (Stern), secure base provision (Bowlby) and holding environment (Winnicott) are all reaching towards the same idea. The function of the parent, of the therapist and of cultural objects can all be understood in this framework of containment and structuring of inchoate experience.
To illustrate his point Rustin contrasts classical and contemporary psychoanalytic accounts of Hamlet. Ernest Jones (1949) saw the play as a quintessentially Oedipal drama in which Hamlet is wracked by his ambivalence towards the father-figures (the Ghost, the King, Polonius), and his simultaneous yearning and rage towards his mother. Williams (Meltzer and Williams 1988) sees the problem of the play centring on Hamlet's search for a vehicle with which to express his grief, anger and ambition. The corrupt world of the court, of institutional power cannot contain this intimacy of the imagination. The play-within-a-play 'catches the conscience of the king', but action - as opposed to thought - spills over into murder and intrigue. Throughout the
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play Hamlet, like a patient in therapy, has been struggling to write his story, to find, in Williams' words, an 'aesthetic correlative to image the idea of a new prince' (that is, one not caught up in power and corruption). Dying, he enjoins his faithful Horatio to
Absent thee from felicity awhile,
And in this harsh world draw thy breath in pain To tell my story.
In this neo-Kleinian perspective, narrative becomes a key feature of the psychotherapeutic process. The therapist provides a setting in which thought rather than action can happen, and in which the patient can begin to tell himself his own story, undistorted by repression, splitting and affective distancing. In the Lacanian (Bowie 1991) account too, narrative is central, although a 'story', spoken in words, is seen as the imposition of the logos, of phallocentric culture on the primal, pre- verbal unity of mother and child. For the Kleinians there is no such radical rupture with the onset of language: integration is achieved at the advent of the depressive position, rather than thwarted by the insertion of the paternal order.
The aesthetic perspective provides perhaps a much-needed cultural location for psychoanalysis, but what of its claim to be a science, and how do we evaluate one narrative account against another? Are all 'stories' equally valid, or are some more 'true' than others? And what of Bowlby's own comment:
I believe that our discipline can be put on to a scientific basis. A lot of people think you can't or don't know how to. There are people who think psychoanalysis is really a hermeneutic discipline. I think that's all rubbish quite frankly.
(Bowlby et al. 1986)
Bowlby wanted to make psychoanalysis more scientific, claiming to be truer to Freud's intentions and more in touch with his later ideas than were Klein and her followers. He did so at a time when psychoanalysis, partly in spite of itself, was gradually moving away from science and in the direction of hermeneutics and meanings. Attachment theory, like one of Darwin's Galapagos islands, became isolated from the mainland of psychoanalysis, so developing its own ideas and language.
However, to continue the analogy, continental drift has occurred: previously separate areas are now beginning to overlap.
146 Imlications
It is here that the recent work of Main (1991), Fonagy (1991) and Bretherton (1991a and b) are so intriguing. As we showed in the previous chapter, the Adult Attachment Interview is a standardised instrument by which an individual's autobiographical narrative account of their childhood and attachment history can be linked with their behaviour as parents, and with the security of their children. Clear, coherent stories correlate with securely attached children. Narrative incompetence - inability to tell any sort of story, or embroilment in a muddled and incoherent one - is linked with insecure attachment. The narrative dimension in psychotherapy - helping patients to gain a clearer picture of their life and their early attachments - can be supported on scientific as well as aesthetic grounds. The polarisation between hermeneutics and science implicit in Bowlby's rather intemperate dismissal now looks a lot less clear-cut. Psychoanalysis provides a system of meanings for helping to decode patients' symptoms, but, if we step back from the specific meanings, we find good scientific evidence that narrative capacity, the ability to make meanings out of the inchoate flow of an 'unstoried' life - especially out of loss and disappointment - is associated with healthy psychological functioning.
If hermeneutics is 'rubbish' - a view which, had he lived long enough to consider the implications of Main and Fonagy's work, Bowlby might well have revised - what then of the opposing scientific tendency within psychotherapy? Cognitive therapy, devised by Beck et al. (1979), works primarily with cognitions, as opposed to the emotions that are the raw material of psychoanalysis. It is based on the idea that cognitions determine feelings (rather than vice versa), and that if the faulty cognitions which underlie neurotic states can be unearthed and corrected, then psychological health will ensue. There are strong echoes of Bowlbian metapsychology in this model. Mental structures are visualised in a hierarchy of expectations and assumptions, from specific assumptions such as 'When I am distressed I will receive help', to core beliefs such as 'I am lovable and can love'. The internal working models of Attachment Theory are similarly visualised as a set of guiding affective and cognitive models of the world that are more or less subject to revision and updating. Cognitive therapy assumes that in neurosis the normal process of testing and modifying assumptions about the world breaks down, so that, for example, if the core belief in depression is 'I am
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unworthy of love and deserve rejection', when a fortuitous rebuff occurs this serves to reinforce the faulty belief and to deepen the depression.
In Ryle's (1990) modification of cognitive therapy, cognitive analytic therapy (CAT), he considers that the underlying core beliefs have their origins in disturbed attachment patterns in infancy and early childhood, later perpetuated in adult relationships by a vicious circle of self-fulfilling negative assumptions about the self and the world. Ryles's model of therapy requires a much more active collaborative attitude on the part of the therapist than in traditional analytic therapy. The therapist sets tasks for the patient, such as encouraging them to keep a 'mood diary' and to rate their progress on visual scales, as well as offering the patient a written formulation of the problem and its dynamics and a farewell letter when therapy (which is brief - typically sixteen sessions) comes to an end.
CAT is 'Bowlbian' in three important ways. First in its theoretical eclecticism: Ryle happily marries cognitive science with psychoanalysis in an information-processing model that is very similar to Bowlby's attempt to re-write psychoanalytic defense mechanisms in terms of control theory. Second, Ryle's active therapist is engaging in 'companionable interaction' with the patient just like the secure base mother who actively plays with her child, and meeting the need for affiliation postulated by Heard and Lake (1986). Third, like cognitive therapy, CAT focuses on the need for self-reflection by the patient. This links with Fonagy's account of narrative capacity discussed above. In his model the good mother accurately reflects the moods and wishes of her infant. This mirroring is then internalised as self-reflexive capacity, as the child gradually comes to know about his own internal states. This in turn manifests itself, as development proceeds, in the capacity to verbalise these states, and to 'tell a story' about oneself. The main themes of this autobiographical skill are the history of one's attachments, separations and reunions. Being a brief therapy, CAT highlights and tries to accelerate the emergence of autobiographical competence in a deliberate way rather than assuming that it will be an automatic part of the therapeutic process. Post-Bowlbian research provides a rationale for this in that there is a demonstrable link between the capacity to 'tell one's story' and the development of secure attachment which is an overall goal of psychotherapy.
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In summary, Attachment Theory has shown that the emphasis on narrative and hermeneutics in contemporary psychotherapy can be justified on good developmental grounds. Good mothers help their infants towards personal meanings, which in turn are a basis and mark of secure attachment. Cognitive therapy, although apparently opposed to the narrative approach in its concern with here-and-now cognitions, is also, in its way, a story about the internal world. Its 'basic assumptions' are not far removed from Bowlby's internal working models or the 'representational world' of psychoanalysis.
Freud (1911) always insisted that there were two principles of mental functioning, the primary and secondary processes - the visual and the verbal, the imaginative and the rational - and that healthy functioning required a balance between the two. In Humphrey's (1992) re-working of this model there are two channels of information available to the organism, sensation and perception, which tell it about its own internal states and the state of the world respectively. Out of the post-war schisms of psychoanalysis there emerged an unhealthy polarisation between the concern of psychoanalysis with the primary processes and the focus of attachment and cognitive theory on secondary processes. The paradigm of narrative, a blending of sensation and perception, in which the inner world can be described objectively, while the subjective colouring of the outer world is also held up for inspection, is exciting increasing interest in psychotherapy (see Spence 1982; Shafer 1976). The question arises whether a secondary-process type verbal encouragement towards self-observation and narrative capacity is likely in itself to be effective, or whether primary-process ingredients, especially the arousal of affect through transference, are also needed. To consider this and other more practical questions we must now turn to a consideration of the specific implications of the Bowlbian perspective for the practice of psychotherapy.
Chapter 8
Attachment Theory and the practice of psychotherapy
The therapeutic alliance appears as a secure base, an internal object as a working, or representational, model of an attachment figure, reconstruction as exploring memories of the past, resistance as deep reluctance to disobey the past orders of parents not to tell or not to remember. . . . Whilst some traditional therapists might be described as adopting the stance 'I know; I'll tell you', the stance I advocate is one of 'You know, you tell me' . . . the human psyche, like human bones, is strongly inclined towards self-healing. The psychotherapist's job, like that of the orthopaedic surgeon's, is to provide the conditions in which self-healing can best take place.
(Bowlby 1988a)
We come now to the core of the book: an attempt to describe Attachment Theory's distinctive contribution to the theory and practice of psychotherapy. Two related concepts have emerged. The first, starting from Object-Relations Theory, but going beyond it, is the idea of the core state with respect to attachment. Bowlby sees a person's attachment status as a fundamental determinant of their relationships, and this is reflected in the way they feel about themselves and others. Neurotic patterns can be seen as originating here because, where core attachments are problematic, they will have a powerful influence on the way someone sees the world and their behaviour. Where there is a secure core state, a person feels good about themselves and their capacity to be effective and pursue their projects. Where the core state is insecure, defensive strategies come into play.
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Bowlby's concept of defence is different from that of classical psychoanalysis (Hamilton 1985) in that it is not primarily intra- psychic - a way of reducing the internal disruption created by unmanageable feelings - but interpersonal. Secure attachment provides a positive 'primary' defence; 'secondary', pathological defences are methods of retaining proximity to rejecting or unreliable attachment figures. The two main patterns can be formulated along the lines of 'I need to be near to my attachment figures in order to feel safe, but they may reject my advances, so I will suppress my needs both from myself and them, and remain on the emotional periphery of relationships' (avoidant strategy), or 'I need to be near to my attachment figures but they may fail to respond to me or intrude on me in a way I can't control, so I will cling to them and insist on their responding to and caring for me' (ambivalent strategy). Both can be formulated in terms of dilemmas (Ryle 1990) arising out of the need to get close and the imagined dangers of so doing: rejection, abandonment or intrusion. Both lead to inhibition of vital parts of personality functioning. In avoidance, aggression tends to be displaced or split off; in ambivalence, exploration is held back.
The second central concept to have emerged from Attachment Theory is that of narrative. A person's core state is a condensate of the history of their primary relationships. If this history is available to them in the form of a personal narrative, then they are likely to feel secure. We have seen in Chapter 6 the evidence that 'autobiographical competence' (Holmes 1992) both results from and contributes to secure attachment. The word 'narrative' derives from gnathos or knowing. Psychotherapy is based on the Delphic injunction (Pedder 1982): know thyself. Making the unconscious conscious can be re-formulated as knowing and owning one's story. Attachment Theory has shown that self- knowledge in the form of narrative is associated with a core state characterised by secure attachment. Narrative turns experience into a story which is temporal, is coherent and has meaning. It objectifies experience so that the sufferer becomes detached from it, by turning raw feeling into symbols. It creates out of fragmentary experience an unbroken line or thread linking the present with the past and future. Narrative gives a person a sense of ownership of their past and their life.
Contemporary psychotherapy is characterised by a myriad of different schools and models of the therapeutic process.
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Attachment Theory should not be seen as yet one more form of psychotherapy, but rather as defining features that are relevant to therapy generally - individual, group, family - akin to Frank's (1986) common factors or 'metamodel' approach to the diversity of therapies. He proposes certain key elements which are shared by all therapies. These include a relationship with the therapist, which provides hope or 'remoralisation' - in Bowlbian terms a secure base from which to start to explore the problem; a coherent explanation for the patient's difficulties - a shared narrative; and a method for overcoming them. Holmes and Lindley (1989) saw the overall goal of psychotherapy as 'emotional autonomy' - the capacity to form relationships in which one feels both close and free, corresponding with Attachment Theory's picture of a secure base facilitating exploration.
This chapter will be devoted to a discussion of five key themes which determine an individual's core state of attachment, and how psychotherapy may help, via the development of a therapeutic narrative, to create secure rather than neurotic (that is, insecure) attachments. These are: the need for a secure therapeutic base; the role of real trauma (as opposed to phantasy) in the origins of neurosis; affective processing, especially of loss and separation; the place of cognitions in therapy; and the part played by 'companionable interaction' between therapist and patient. The main focus will be on individual therapy, but the principles are equally applicable to group therapies, and the chapter ends with a consideration of Attachment Theory in relation to family therapy, of which Bowlby was one of the founding fathers.
1 ATTACHMENT AND THE SECURE BASE IN PSYCHOTHERAPY
Attachment Theory predicts that when someone is faced with illness, distress, or threat they seek out an attachment figure from whom they may obtain relief. Once a secure base is established attachment behaviour is assuaged, and they can begin to explore - in this case, the exploration will be of the situation which has caused the distress and the feelings it has aroused. This would be a simple account of many episodes of brief counselling, and of psychotherapy generally were it not for the question of the nature of the secure base. The establishment of a base depends on the interaction between help-seeker and help-giver. The very fact that
152 Imlications
someone seeks psychotherapeutic help implies that they will have had difficulty in establishing such a base in the past. The patient brings with him into therapy all the failures and suspicions and losses he has experienced through his life. The defensive forms of insecure attachment - avoidance, ambivalence, disorganisation - will be brought into play in relation to the therapist. There will be a struggle between these habitual patterns and the skill of the therapist in providing a secure base - the capacity to be responsive and attuned to the patient's feelings, to receive projections and to transmute them in such a way that the patient can face their hitherto unmanageable feelings. To the extent that this happens, the patient will gradually relinquish their attachment to the therapist while, simultaneously, an internal secure base is built up inside. As a result, as therapy draws to a close, the patient is better able to form less anxious attachment relationships in the external world and feels more secure in himself. As concrete attachment to the therapist lessens, so the qualities of self- responsiveness and self-attunement are more firmly established in the inner world.
Freud wrote in 1913: 'The first aim of the treatment consists in attaching . . . [the patient] to the treatment and to the person of the physician. ' Psychoanalysts have worried about two aspects of this attachment. First, can healthy, conscious, therapeutic attachment be distinguished from unconscious phantasy-based transferential feelings aroused in the patient by being in treatment? Second, is it the secure base of this relationship and the 'new beginning' (Balint 1968) which provide the main vehicle of cure, or are interpretations and the insight they produce the crucial factors?
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'.