Good
therapists
find themselves automatically mirroring their patients' levels of speech volume and their posture.
Bowlby - Attachment
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)
142 Imlications
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)
Bowlby and the inner world 143
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
Bowlby and the inner world 145
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
Bowlby and the inner world 147
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.
148 Imlications
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'. 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.
Attachment Theory and psychotherapy 153
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.
154 Imlications
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
Attachment Theory and psychotherapy 155
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
156 Imlications
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
158 Imlications
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.
162 Imlications
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.
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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.
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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
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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'. 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.
