No More Learning

? ? child will behave in a nursery group (with mother absent) three and a half years later. Thus children who showed a secure pattern with mother at 12 months are likely to be described by nursery staff as co-operative, popular with other children, resi- lient, and resourceful. Those who showed an anxious avoidant pattern are likely to be de- scribed as emotionally insulated, hostile or anti- social and, paradoxically, as unduly seeking of at- tention. Those who showed an anxious resistant pattern are likely to be described as also unduly seeking of attention and as either tense, impuls- ive, and easily frustrated or else as passive and helpless (Sroufe, 1983). In view of these findings it is hardly surprising that in two other prospect- ive studies, a pioneering one in California (Main and Cassidy, 1988) and a replicative one in Ger- many (Wa? rtner, 1986), the pattern of attachment assessed at 12 months is found to be highly pre- dictive also of patterns of interaction with mother five years later.
Although the repertoire of a 6-year-old's beha- viour towards a parent is vastly greater than that of a one-year-old, the earlier patterns of attach- ment are nonetheless readily discernible to an educated eye at the older age. Thus children who
259/362
? ? ? are classified as being securely attached at 6 years are those who treat their parents in a relaxed and friendly way, who enter into easy, and often subtle, intimacies with them, and who engage in free-flowing conversation. Children classified as anxious resistant show a mixture of insecurity, including sadness and fear, and of intimacy al- ternating with hostility, which is sometimes subtle and at others overt. In some of these cases the child's behaviour strikes an observer as self- conscious, even artificial. As though they were al- ways anticipating a negative response from the parent, they try to ingratiate themselves by show- ing off, perhaps by being cute or especially charming (Main and Cassidy, 1988; Main, per- sonal communication).
Children aged 6 years classified as anxious avoidant tend quietly to keep the parent at a dis- tance. Such greetings as they give are formal and brief; topics of conversation stay impersonal. He or she keeps busy with toys or some other activity and ignores or is even dismissive of a parent's initiatives.
Children who at 12 months appeared to be dis- organized and/or disoriented are found five years later to be conspicuous for their tendency to
260/362
? ? ? control or dominate a parent. One form of this is to treat the parent in a humiliating and/or reject- ing way; another is to be solicitous and protect- ive. These are clear examples of what clinicians have labelled as an inversion, or reversal, of the child and parent roles. Conversations between them are fragmented, sentences begun but left unfinished, topics broached but changed abruptly.
In considering the persistence of a 6-year-old's patterns of interaction with parents and with oth- er parental figures, a critical question arises: to what extent are the patterns at this age ingrained within the child's personality and to what extent are they a reflection of the way the parents still treat him or her? The answer, to which clinical experience points, is that by this age both these influences are at work so that the most effective interventions are those that take both into ac- count, e. g. by means either of family therapy or else by giving help in parallel to parents and child.
As yet too little is known about how the influ- ence on personality development of interactions with the mother compares with the influence of those with the father. It would hardly be
261/362
? ? ? surprising were different facets of personality, manifest in different situations, to be influenced differently. In addition, their respective influ- ences on males may be expected to differ from their respective influences on females. It is clearly a complex area that will require much research. Meanwhile it seems likely that, at least during the early years of an individual's life, the model of self interacting with mother is the more influen- tial of the two. This would hardly be surprising since in every culture known the huge majority of infants and young children interact far more with the mother than with the father.
It must be recognized that, so far, prospective studies of the relative persistence of patterns of attachment, and of the features of personality characteristic of each, have not yet been carried beyond the sixth year. Even so, two cross-section- al studies of young adults show that the features of personality characteristic of each pattern dur- ing the early years are also to be found in young adults (Kobak and Sceery, 1988; Cassidy and Kobak, 1988; Hazan and Shaver, 1987); and it is more than likely that, except in cases where fam- ily relations have changed substantially in the in- terval, they have been present continuously. All
262/362
? ? ? our clinical experience strongly supports that view.
A THEORY OF INTERNALIZATION
In order to account for the tendency for patterns of attachment increasingly to become a property of the child himself, attachment theory invokes the concept of working models of self and of par- ents already described. The working models a child builds of his mother and her ways of com- municating and behaving towards him, and a comparable model of his father, together with the complementary models of himself in interaction with each, are being built by a child during the first few years of his life and, it is postulated, soon become established as influential cognitive structures (Main, Kaplan, and Cassidy, 1985). The forms they take, the evidence reviewed strongly suggests, are based on the child's real- life experience of day-to-day interactions with his parents. Subsequently the model of himself that he builds reflects also the images that his parents have of him, images that are communicated not only by how each treats him but by what each says to him. These models then govern how he feels towards each parent and about himself, how
263/362
? ? ? he expects each of them to treat him, and how he plans his own behaviour towards them. They gov- ern too both the fears and the wishes expressed in his day dreams.
Once built, evidence suggests, these models of a parent and self in interaction tend to persist and are so taken for granted that they come to operate at an unconscious level. As a securely at- tached child grows older and his parents treat him differently, a gradual up-dating of models occurs. This means that, though there is always a time-lag, his currently operative models continue to be reasonably good simulations of himself and his parents in interaction. In the case of the anxiously attached child, by contrast, this gradual up-dating of models is in some degree obstructed through defensive exclusion of discrepant experi- ence and information. This means that the pat- terns of interaction to which the models lead, having become habitual, generalized, and largely unconscious, persist in a more or less uncorrec- ted and unchanged state even when the individu- al in later life is dealing with persons who treat him in ways entirely unlike those that his parents adopted when he was a child.
264/362
? ? ? The clue to an understanding of these differ- ences in the degree to which models are up-dated is to be found in the profound differences in the freedom of communication between mother and child that characterize pairs of the two types. This is a variable to which Bretherton (1987) has drawn especial attention.
It will be noticed that in Main's longitudinal study described above the pattern of communica- tion between a 6-year-old child and his mother, as observed in a pair that, five years earlier, had shown a secure pattern of attachment, is very dif- ferent from that observed in a pair who had earli- er shown an insecure pattern. Whereas the secure pairs engaged in free-flowing conversation laced with expressions of feeling, and touching on a variety of topics including personal ones, the in- secure pairs did not. In some, conversation was fragmented and topics abruptly changed. In oth- ers, notably the avoidant pairs, conversation was limited, topics kept impersonal, and all reference to feeling omitted. These striking differences in the degree to which communication is either free or restricted are postulated to be of great relev- ance for understanding why one child develops healthily and another becomes disturbed.
265/362
? ? ? Moreover it will not have escaped notice that this same variable, the degree to which communica- tion between two individuals is restricted or rel- atively free, has for long been recognized as one of central concern in the practice of analytic psychotherapy.
For a relationship between any two individuals to proceed harmoniously each must be aware of the other's point-of-view, his goals, feelings, and intentions, and each must so adjust his own be- haviour that some alignment of goals is negoti- ated. This requires that each should have reason- ably accurate models of self and other which are regularly up-dated by free communication between them. It is here that the mothers of the securely attached children excel and those of the insecure are markedly deficient.
Once we focus on the degree to which commu- nication between a parent-child pair is free-flow- ing or not, it quickly becomes apparent that, from the earliest days of life, the degree of freedom of communication in the pairs destined to develop a secure pattern of attachment is far greater than it is in those who do not (Ainsworth, Bell, and Stayton, 1971; Blehar, Lieberman, and Ainsworth, 1977). Thus it is characteristic of a mother whose
266/362
? ? ? infant will develop securely that she is continu- ously monitoring her infant's state and, as and when he signals wanting attention, she registers his signals and acts accordingly. By contrast, the mother of an infant later found to be anxiously attached is likely to monitor her infant's state only sporadically and, when she does notice his signals, to respond tardily and/or inappropri- ately. By the time an infant has reached his first birthday, moreover, these differences in freedom of communication have been found to be clearly evident during the Ainsworth Strange Situation procedure (Grossmann, Grossmann, and Sch- wan, 1986). Even in the introductory episode, when infant and mother are alone together, more of the secure pairs were observed to engage in direct communication, by eye contact, facial ex- pression, vocalization, and showing or giving toys, than did the insecure pairs. As the stress on the child increases, so do the differences between the pairs. Thus in the reunion episode after the second separation all but one of 16 secure pairs communicated in direct fashion in contrast to a minority of the insecure ones. There was one oth- er very striking difference moreover. Whereas every infant classified as secure was seen to be in
267/362
? ? ? direct communication with his mother, not only when he was content but also when he was dis- tressed, the infants classified as avoidant, when they did engage in direct communication, did so only when they were content.
Thus already by the age of 12 months there are children who no longer express to their mothers one of their deepest emotions or the equally deep-seated desire for comfort and reassurance that accompanies it. It is not difficult to see what a very serious breakdown of communication between child and mother this represents. Not only that but, because a child's self-model is pro- foundly influenced by how his mother sees and treats him, whatever she fails to recognize in him he is likely to fail to recognize in himself. In this way, it is postulated, major parts of a child's de- veloping personality can become split off from, that is, out of communication with, those parts of his personality that his mother recognizes and re- sponds to, which in some cases include features of personality that she is attributing to him wrongly.
The upshot of this analysis is that obstruction to communication between different parts of, or systems within, a personality, which from the
268/362
? ? ? earliest days Freud saw as the crucial problem to be solved, is now seen as a reflection of the differ- ential responses and communications of a moth- er to her child. When a mother responds favour- ably only to certain of her child's emotional com- munications and turns a blind eye or actively dis- courages others, a pattern is set for the child to identify with the favoured responses and to dis- own the others.
It is along these lines that attachment theory explains the differential development of resilient and mentally healthy personalities, and also of personalities prone to anxiety and depression, or to developing a false self or some other form of vulnerability to mental ill-health. Perhaps it is no coincidence that some of those who approach problems of personality development and psy- chopathology from a cognitive standpoint, but who also give weight to the power of emotion, e. g. Epstein (1980, 1986) and Liotti (1986, 1987), have been formulating theories that are essen- tially compatible with this one.
VARIATIONS IN A MOTHER'S WAY OF RECALLING HER CHILDHOOD EXPERIENCE
269/362
? ? ? The conclusion so far reached about the role of free communication, emotional as well as cognit- ive, in determining mental health is strongly sup- ported by an important recent finding from Main's longitudinal study. As a result of inter- viewing the mothers of the children in the study, Main found a strong correlation between how a mother describes her relationships with her par- ents during her childhood and the pattern of at- tachment her child now has with her (Main, Ka- plan, and Cassidy, 1985; see also Morris, 1981 and Ricks, 1985). Whereas the mother of a secure infant is able to talk freely and with feeling about her childhood, the mother of an insecure infant is not.
In this part of the study an interviewer asks the mother for a description of her early relation- ships and attachment-related events and for her sense of the way these relationships and events affected her personality. In considering results, as much or more attention is paid to the way a mother tells her story and deals with probing questions about it as to the historical material she describes. At the simplest level, it was found that a mother of a secure infant is likely to report hav- ing had a reasonably happy childhood and to
270/362
? ? ? show herself able to talk about it readily and in detail, giving due place to such unhappy events as may have occurred as well as to the happy ones. By contrast, a mother of an insecure infant is likely to respond to the enquiry in one of two dif- ferent ways. One, shown by mothers of anxious resistant children, is to describe a difficult un- happy relationship with her own mother about which she is still clearly disturbed and in which she is still entangled mentally, and, should her mother be still alive, it is evident that she is en- tangled with her in reality as well. The other, shown by mothers of anxious avoidant children, is to claim in a generalized matter-of-fact way that she had a happy childhood, but not only is she unable to give any supporting detail but may refer to episodes pointing in an opposite direc- tion. Frequently such a mother will insist that she can remember nothing about her childhood nor how she was treated. Thus the strong impression of clinicians, that a mother who had a happy childhood is likely to have a child who shows a secure attachment to her, and that an unhappy childhood, more or less cloaked by an inability to recall, makes for difficulties, is clearly supported.
271/362
? ? ? Nevertheless a second finding, no less interest- ing and one of especial relevance here, arises from a study of the exceptions to the general rule. These are the mothers who describe having had a very unhappy childhood but who nonetheless have children showing secure attachment to them. A characteristic of each of these mothers, which distinguishes them from mothers of insec- ure infants, is that, despite describing much re- jection and unhappiness during childhood, and perhaps tearful whilst doing so, each is able to tell her story in a fluent and coherent way, in which such positive aspects of her experiences as there were are given a due place and appear to have been integrated with all the negative ones. In their capacity for balance they resemble the other mothers of secure infants. It seemed to the inter- viewers and those assessing the transcripts that these exceptional mothers had thought much about their unhappy earlier experiences and how it had affected them in the long term, and also about why their parents might have treated them as they had. In fact, they seemed to have come to terms with their experience.
By contrast, the mothers of children whose pat- tern of attachment to them was insecure and who
272/362
? ? ? also described an unhappy childhood did so with neither fluency nor coherence: contradictions abounded and went unnoticed. Moreover, it was a mother who claimed an inability to recall her childhood and who did so both repeatedly and strongly who was a mother whose child was in- secure in his relation to her. 2
In the light of these findings Main and her col- leagues conclude that free access to, and the co- herent organization of information relevant to at- tachment play a determining role in the develop- ment of a secure personality in adult life. For someone who had a happy childhood no obstacles are likely to prevent free access to both the emotional and the cognitive aspects of such information. For someone who suffered much unhappiness or whose parents forbade him or her to notice or to remember adverse events, ac- cess is painful and difficult, and without help may indeed be impossible. Nevertheless, however she may accomplish it, when a woman manages either to retain or to regain access to such un- happy memories and reprocess them in such a way that she can come to terms with them, she is found to be no less able to respond to her child's attachment behaviour so that he develops a
273/362
? ? ? secure attachment to her than a woman whose childhood was a happy one. This is a finding to give great encouragement to the many therapists who for long have sought to help mothers in just this kind of way. Further reference to techniques for helping disturbed mothers is made at the end of Lecture 8.
PATHWAYS TO PERSONALITY DEVELOPMENT
There is one further way in which attachment theory differs from traditional types of psycho- analytic theory, namely its rejection of the model of development in which an individual is held to pass through a series of stages in any one of which he may become fixated or to which he may regress, and its replacement by a model in which an individual is seen as progressing along one or another of an array of potential developmental pathways. Some of these pathways are compat- ible with healthy development; others deviate in one or another direction in ways incompatible with health.
All variants of the traditional model invoking phases of development are based on the assump- tion that, at some phase of normal development, a child shows psychological features that, in an
274/362
? ? ? older individual, would be regarded as signs of pathology. Thus a chronically anxious and cling- ing adult might be regarded as being fixated in or having regressed to a postulated phase of orality or of symbiosis; whilst a deeply withdrawn indi- vidual might be regarded as having regressed to a postulated phase of autism or of narcissism. Sys- tematic and sensitive studies of human infants, such as those reported by Stern (1985), have now rendered this model untenable. Observations show that infants are socially responsive from birth onwards. Healthily developing toddlers do not show anxious clinging except when they are frightened or distressed; at other times they ex- plore with confidence.
The model of developmental pathways regards an infant at birth as having an array of pathways potentially open to him, the one along which he will in fact proceed being determined at every moment by the interaction of the individual as he now is with the environment in which he happens then to be. Each infant is held to have his own in- dividual array of potential pathways for personal- ity development which, except for infants born with certain types of neurological damage, in- clude many that are compatible with mental
275/362
? ? ? health and also many that are incompatible. Which particular pathway he proceeds along is determined by the environment he meets with, especially the way his parents (or parent substi- tutes) treat him, and how he responds to them. Children who have parents who are sensitive and responsive are enabled to develop along a healthy pathway. Those who have insensitive, unrespons- ive, neglectful, or rejecting parents are likely to develop along a deviant pathway which is in some degree incompatible with mental health and which renders them vulnerable to breakdown, should they meet with seriously adverse events. Even so, since the course of subsequent develop- ment is not fixed, changes in the way a child is treated can shift his pathway in either a more fa- vourable direction or a less favourable one. Al- though the capacity for developmental change di- minishes with age, change continues throughout the life cycle so that changes for better or for worse are always possible. It is this continuing potential for change that means that at no time of life is a person invulnerable to every possible ad- versity and also that at no time of life is a person impermeable to favourable influence. It is this
276/362
? ? ? persisting potential for change that gives oppor- tunity for effective therapy.
1 In earlier publications I have sometimes used the term 'representational model' as a synonym for 'work- ing model' because representation has been the more familiar concept in clinical literature. In a dynamic psychology, however, working model is the more ap- propriate term, and it is also the term that is now com- ing into use among cognitive psychologists (e. g. Johnson-Laird, 1983). Within the attachment frame- work the concept of working model of an attachment figure is in many respects equivalent to, and replaces, the traditional psychoanalytic concept of internal object.
2 In further examination of the data it has been found that all these correlations also hold true for fathers (Main, personal communication).
8
ATTACHMENT, COMMUNICATION, AND THE THERAPEUTIC PROCESS
In the second part of my 1976 Maudsley Lecture, 'The making and breaking of affectional bonds' (1977), I described some of my ideas on the therapeutic implications of attachment theory. Much that has been learned since then has strengthened my confidence in the approach. The present account therefore should be re- garded as an amplification of the earlier one. In it I give more detailed attention to the ways a patient's earlier experiences affect the transfer- ence relationship and discuss further the therap- ist's aim as being that of enabling his patient to reconstruct his working models of himself and his attachment figure(s) so that he becomes less under the spell of forgotten miseries and better able to recognize companions in the present for what they are.
? 278/362
? ? ? a thing which has not been understood inevitably reappears; like an unlaid ghost, it cannot rest until the mystery has been resolved and the spell broken.
Sigmund Freud 1909
Those who cannot remember the past are condemned to repeat it. George Santayana 1905
FIVE THERAPEUTIC TASKS
The theory of personality development and psy- chopathology outlined above can be used as a framework to guide each one of the three princip- al forms of analytic psychotherapy in use today--individual therapy, family therapy, and group therapy. Here I deal only with the first.
A therapist applying attachment theory sees his role as being one of providing the conditions in which his patient can explore his representational models of himself and his attachment figures with a view to reappraising and restructuring them in the light of the new understanding he ac- quires and the new experiences he has in the therapeutic relationship. In helping his patient towards this end the therapist's role can be de- scribed under five main heads.
The first is to provide the patient with a secure base from which he can explore the various un- happy and painful aspects of his life, past and
279/362
? ? ? present, many of which he finds it difficult or per- haps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.
A second is to assist the patient in his explora- tions by encouraging him to consider the ways in which he engages in relationships with significant figures in his current life, what his expectations are for his own feelings and behaviour and for those of other people, what unconscious biases he may be bringing when he selects a person with whom he hopes to make an intimate relationship and when he creates situations that go badly for him.
A particular relationship that the therapist en- courages the patient to examine, and that consti- tutes the third task, is the relationship between the two of them. Into this the patient will import all those perceptions, constructions, and expecta- tions of how an attachment figure is likely to feel and behave towards him that his working models of parents and self dictate.
A fourth task is to encourage the patient to consider how his current perceptions and expect- ations and the feelings and actions to which they
280/362
? ? ? give rise may be the product either of the events and situations he encountered during his child- hood and adolescence, especially those with his parents, or else as the products of what he may repeatedly have been told by them.
This is often a painful and difficult process and not infrequently requires that the therapist sanction his patient to consider as possibilities ideas and feelings about his parents that he has hitherto regarded as un- imaginable and unthinkable. In doing so a pa- tient may find himself moved by strong emotions and urges to action, some directed towards his parents and some towards the therapist, and many of which he finds frightening and/or alien and unacceptable.
The therapist's fifth task is to enable his patient to recognize that his images (models) of himself and of others, derived either from past painful experiences or from misleading messages eman- ating from a parent, but all to often in the literat- ure mislabelled as 'fantasies', may or may not be appropriate to his present and future; or, indeed, may never have been justified. Once he has grasped the nature of his governing images (mod- els) and has traced their origins, he may begin to understand what has led him to see the world and
281/362
? ? ? himself as he does and so to feel, to think, and to act in the ways he does. He is then in a position to reflect on the accuracy and adequacy of those im- ages (models), and on the ideas and actions to which they lead, in the light of his current experi- ences of emotionally significant people, including the therapist as well as his parents, and of himself in relationship to each. Once the process has star- ted he begins to see the old images (models) for what they are, the not unreasonable products of his past experiences or of what he has repeatedly been told, and thus to feel free to imagine altern- atives better fitted to his current life. By these means the therapist hopes to enable his patient to cease being a slave to old and unconscious stereo- types and to feel, to think, and to act in new ways.
Readers will be aware that the principles set out have a great deal in common with the prin- ciples described by other analytically trained psy- chotherapists who regard conflicts arising within interpersonal relationships as the key to an un- derstanding of their patient's problems, who fo- cus on the transference and who also give some weight, albeit of varying degree, to a patient's earlier experience with his parents. Among the many well-known names that could be
282/362
? ? ? mentioned in this context are those of Fairbairn, Winnicott, and Guntrip in Britain, and Sullivan, Fromm-Reichmann, Gill, and Kohut in the Un- ited States. Among recently published works that contain many of the ideas prescribed here are those by Peterfreund (1983), Casement (1985), Pine (1985), and Strupp and Binder (1984), and also those of Malan (1973) and Horowitz et al. (1984) in the field of brief psychotherapy. In par- ticular, I wish to draw attention to the ideas of Horowitz and his colleagues who, in their de- scription of the treatment of patients suffering from an acute stress syndrome, employ a concep- tual framework closely similar to that presented here. Although their technique is aimed to help patients recover from the effects of a recent severely stressful event, I believe the principles informing their work are equally applicable to helping patients recover from the effects of a chronic disturbance resulting from stressful events of many years ago, including those that oc- curred during their earliest years.
Although in this exposition it is convenient to list the therapist's five tasks in a logical way, so inter- related are they that in practice a productive ses- sion is likely to involve first one task, then
283/362
? ? ? another. Nevertheless, unless a therapist can en- able his patient to feel some measure of security, therapy cannot even begin. Thus we start with the role of the therapist in providing his patient with a secure base. This is a role very similar to that described by Winnicott as 'holding' and by Bion as 'containing'.
In providing his patient with a secure base from which to explore and express his thoughts and feelings the therapist's role is analogous to that of a mother who provides her child with a se- cure base from which to explore the world. The therapist strives to be reliable, attentive, and sympathetically responsive to his patient's ex- plorations and, so far as he can, to see and feel the world through his patient's eyes, namely to be empathic. At the same time he is aware that, be- cause of his patient's adverse experiences in the past, the patient may not believe that the therap- ist is to be trusted to behave kindly or to under- stand his predicament. Alternatively the unex- pectedly attentive and sympathetic responses the patient receives may lead him to suppose that the therapist will provide him with all the care and affection which he has always yearned for but never had. In the one case therefore the therapist
284/362
? ? ? is seen in an unduly critical and hostile light, in the other as ready to provide more than is at all realistic. Since, it is held, both types of misunder- standing and misconstruction, and the emotions and behaviour to which they give rise, are central features of the patient's troubles, a therapist needs to have the widest possible knowledge of the many forms these misconstructions can take and also of the many types of earlier experience from which they are likely to have sprung. Without such knowledge a therapist is poorly placed to see and feel the world as his patient is doing.
Even so, a patient's way of construing his rela- tionship with his therapist is not determined solely by the patient's history: it is determined no less by the way the therapist treats him. Thus the therapist must strive always to be aware of the nature of his own contribution to the relationship which, amongst other influences, is likely to re- flect in one way or another what he experienced himself during his own childhood. This aspect of therapy, the counter-transference, is a big issue of its own and the subject of a large literature. Since it is not possible to deal with it further here, I want to emphasize not only the importance of
285/362
? ? ? the counter-transference but also that the focus of therapy must always be on the interactions of patient and therapist in the here and now, and that the only reason for encouraging the patient at times to explore his past is for the light it throws on his current ways of feeling and dealing with life.
With that proviso firmly in mind, let us con- sider some of the commoner forms that a pa- tient's misconstructions can take and how they are likely to have originated. This is the aspect of therapy in which the work of a therapist who ad- opts attachment theory is likely to differ most from one who adopts certain of the traditional theories of personality development and psycho- pathology. Thus, for example, a therapist who views his patient's misperceptions and misunder- standings as the not unreasonable products of what the patient has actually experienced in the past, or has repeatedly been told, differs sharply from one who sees these same misperceptions and misunderstandings as the irrational offspring of autonomous and unconscious fantasy.
In what follows I am drawing on several dis- tinct sources of information: studies by epidemi- ologists; the studies by developmental
286/362
? ? ? psychologists already referred to; observations made during the course of family therapy; and not least what I have learned from patients whom I have treated myself and from those whose ther- apy I have supervised.
INFLUENCE OF EARLIER EXPERIENCES ON THE TRANSFERENCE RELATIONSHIP
It not infrequently happens that a patient is acutely apprehensive lest his therapist reject, cri- ticize, or humiliate him. Since we know that all too many children are treated in this way by one or other, or both, of their parents, we can be reas- onably confident that that has been our patient's experience. Should it seem likely that the patient is aware of how he is feeling and how he expects the therapist to treat him, the therapist will indic- ate that he also is aware of the problem. How soon the therapist can link these expectations to the patient's experiences of his parents, in the present perhaps as well as the past, turns on how willing the patient is to consider that possibility, or whether, by contrast, he insists that his par- ents' treatment of him is above criticism. Where the latter situation obtains, there is the prior problem of trying to understand why the patient
287/362
? ? ? should insist on retaining this favourable picture when such evidence as is available points to its being mistaken.
It happens in some families that one or other parent insists that he or she is an admirable par- ent who has always done everything possible for the child and that, in so far as friction is present, the fault lies exclusively with the child. This atti- tude of the parent all too often cloaks behaviour that, by ordinary standards, has been far from perfect. Yet, since the parent insists that he or she has given the child constant affection and that the child must have been born bad and ungrateful, the child has little option but to accept the pic- ture, despite being aware somewhere in his mind that the picture is hardly fair.
An added complication arises when a patient has, as a child, been subjected to the strongest of instructions from a parent on no account to tell anyone of certain happenings within the family. These are usually quarrels in which the parent is aware that his or her behaviour is open to criti- cism; for example, quarrels between the parents, or between a parent and a child, during which dreadful things have been said or done. The more insistent a therapist is that his patient tell
288/362
? ? ? everything, the more distressing the dilemma is for his patient. Injunctions to silence are not un- common in families and have been much neg- lected as sources of what has traditionally been called resistance. It is often useful for a therapist to enquire of a patient whether he may have been subjected to such pressures and, if so, to help him resolve the dilemma.
So far we have been considering cases in which a patient is in some degree aware of his expecta- tions of being rejected, criticized, or humiliated. Not infrequently, however, a patient seems wholly unaware of any such feelings despite his attitude to the therapist exuding distrust and eva- sion. Evidence shows that these states of mind occur especially in those who, having developed an anxiously avoidant pattern of attachment dur- ing early years, have striven ever since to be emotionally self-contained and insulated against intimate contacts with other people. These pa- tients, who are often described as being narciss- istic or as having a false self, avoid therapy as long as they can and, should they undertake it, keep the therapist at arm's length. If allowed to, some will talk incessantly about anything and everything except emotionally charged
289/362
? ? ? relationships, past or present. Others will explain that they have nothing to talk about. One young woman, whose every move indicated deep dis- trust of me, spent the time boasting of her delin- quent exploits, many of them fictitious I suspec- ted, and pouring contempt on what she insisted was my dull and narrow life. To treat such deeply distrustful people was compared many years ago by Adrian Stephen (1934) with trying to make friends with a shy or frightened pony: both situ- ations require a prolonged, quiet, and friendly patience. Only when the therapist is aware of the constant rebuffs the patient is likely to have been subjected to as a child whenever he sought com- fort or help, and of his terror of being subjected to something similar from the therapist, can the latter see the situation between them as his pa- tient is seeing it.
Another and quite different cause of wariness of any close contact with a therapist for the pa- tient is dread lest the therapist trap him into a re- lationship aimed to serve the therapist's interests rather than his own. A common origin of such fear is a childhood in which a parent, almost al- ways mother, has sought to make the child her own attachment figure and caregiver, that is, has
290/362
? ? ? inverted the relationship. Very often this is done unconsciously and using techniques that, to an uninformed eye, may appear to be overindul- gence but that are really bribes to retain the child in a caregiving role.
Not infrequently a patient shifts during the therapy from treating his therapist as though he was one or other of his parents to behaving to- wards him in the way one of his parents had treated him. For example, a patient who has been subjected to hostile threats as a child may use hostile threats to his therapist. Experiences of scornful contempt from a parent may be re-en- acted as scornful contempt of the therapist. Sexu- al advances from a parent may reappear as sexual advances to the therapist. Such behaviour may be understood in the following way. During his childhood a person learns two principal forms of behaviour and builds in his mind two principal types of model. One form of behaviour is, of course, that of a child, namely himself, interact- ing with a parent, his mother or his father. The corresponding working models he builds are those of himself as a child in interaction with each parent. The other form of behaviour is that of a parent, namely his mother or his father,
291/362
? ? ? interacting with a child, himself. The correspond- ing models he builds are those of each parent in interaction with himself. Therefore, whenever a therapist is puzzled by, or resentful of, the way he is being treated by a patient, he is always wise to enquire when and from whom the patient may have learned that way of treating other people. More often than not it is from one of his parents. 1
With some patients the therapeutic relation- ship is one in which anxiety, distrust, and criti- cism, and sometimes also anger and contempt, are overt and predominate, and the therapist seen in dark colours. Such sentiments as gratit- ude for the therapist's efforts or respect for his competence are conspicuous by their absence. The task then is to help the patient grasp that much of his present resentment stems from past mistreatment at the hands of others and that, however understandable his anger may be as a result, to continue fighting old battles is unpro- ductive. To accept that an unhappy past cannot be changed is usually a bitter pill.
With other patients the situation is reversed: the transference relationship becomes one in which overt gratitude, admiration, and affection are readily expressed, and the therapist seen in a
292/362
? ? ? glow of rosy perfection. Dissatisfaction and criti- cism are notably absent, and anger at the therap- ist's shortcomings, especially absences, unima- ginable. Such idealization of the therapist springs, I believe, partly from unrealistic hopes and expectations of what the therapist is able and willing to provide, and partly from a childhood in which criticism of a parent is forbidden and com- pliance enforced, either by some guilt-inducing technique or else by sanctions such as threats not to love, or even to abandon, the child. With this type of childhood experience, the patient's un- conscious assumption is that the therapist will expect the same degree of obedience as his par- ents had expected and will enforce it by tech- niques or by threats similar to the ones they used.
Unfortunately there has been a tendency in some quarters to confuse the theory advanced here, which regards the way certain parents treat their children as being a major cause of mental ill- health, with an attitude of mind that simply blames parents. No one who works in the fields of child psychiatry and family therapy is likely to make this mistake. On the contrary, as already remarked, it has long been recognized that the misguided behaviour of parents is more often
293/362
? ? ? than not the product of their own difficult and unhappy childhood. As a result much skilled time has always been devoted to helping parents es- cape from the adverse influences of their own childhoods.
Furthermore, during the treatment of an indi- vidual (of any age) who has suffered at the hands of his parents, the therapist, whilst accepting the patient's account, avoids moral judgement. On the contrary, whenever opportunity offers, he will encourage his patient to consider how and why the parent under discussion may have behaved as he or she has done. In raising these questions, it is always useful for the therapist to enquire of the patient what he knows of the childhood experi- ences that the parent in question may have had. Not infrequently this leads the patient to gain some understanding of how things had developed and, from understanding, often to move on to a measure of forgiveness and reconciliation. In family sessions it can be especially valuable if a parent can be encouraged to give an account of his or her childhood. This enables all those present--the parent him- or herself, the spouse, the children, and the therapist--to gain some in- sight into how and why family life has developed
294/362
? ? ? as it has and how each can best help improve it. As already mentioned (p. 150), this strong tend- ency for attachment problems to be transmitted across generations, through the influence on par- enting behaviour of relationship problems stem- ming from the parent's own childhood, is at last receiving the research attention it deserves.
SOME PATHOGENIC SITUATIONS AND EVENTS OF CHILDHOOD
A therapist, I believe, cannot be too well in- formed about the disguised and distorted rela- tionships that can occur in some families, and the terrible things that can happen in others, for it is only if he is so informed that he can have a reas- onably clear idea of what probably lies behind his patient's defences, or of the origins of his anxiety, anger, and guilt. Once he is adequately informed, he is well placed not only to appreciate the truth of what his patient may be describing as having happened to him but also to broach, more or less tentatively, some of the kinds of situation to which the patient may well have been exposed but to which he may be either unable or unwilling to refer. In listing the following situations I am doing no more than indicating some that are both
295/362
? ? ? common and have, until recently, been neglected in the psychotherapeutic literature. 2
Threats not to love a child used as a means of control
It is easy for a mother to say to a child that she will not love him if he behaves in such and such a way. What this means is that the mother is threatening not to provide affection or comfort at times when her child is upset, frightened, or dis- tressed, and not to provide help or encourage- ment at other times. If such threats are used sys- tematically by either parent, or both, the child in- evitably grows up intensely anxious to please and guilt-prone.
Threats to abandon a child
Threats to abandon are a degree more frightening to a child than threats no longer to love him. This is especially so if the parent enacts a threat, per- haps by disappearing herself for a few hours or by packing her child's suitcase and walking him up the street, allegedly to the home for bad boys. Since threats to abandon often take a highly idio- syncratic form, a patient may deny that he was ever subjected to them. In such cases the truth
296/362
? ? ? may emerge with its accompanying emotion only when the special way in which the threat was phrased is recollected. One example is a mother who had concocted the story that a yellow van would draw up and take her son away. Another is a father whose story was that his daughter would be sent to a school on a remote rock surrounded by sharks (Marrone, 1984). Thus, in the first case, all the mother had to say was 'Well the yellow van will come', and, in the second, for the father to say 'Then it will be the rock school', for the child instantly to desist from whatever he or she was doing. In a third case, the code word was 'mar- garine', the mother having coupled her threat to send her son away to a children's home with an insistence that he would have to eat margarine there. For these patients a general phrase like 'threat to abandon' had failed to ring a bell. Only when the code word was unearthed was the ori- ginal terror experienced afresh and the source of the separation anxiety located.
Threats to commit suicide
Sometimes a distraught parent threatens to com- mit suicide if some distressing situation contin- ues. This may occur during quarrels between
297/362
? ? ? parents, which the child overhears, or may be dir- ected at the child himself. In either case such threats strike terror. One lesson to be learned from these cases is that, whenever a patient refers to his parents as having quarrelled, the therapist should always enquire 'What did they say to each other? ' Not infrequently a patient blocks at this. In a fit of temper quarrelling parents may say ap- palling things to each other. This is bad enough. What makes it far worse is when, after cooling down, they disclaim having said any such thing.
Disclaimers and disconfirmations
Examples of disclaimers by a parent of what he or she has said or done, and persistent efforts to dis- confirm what a child has seen or heard, are given in some detail in Lecture 6 and the adverse ef- fects on personality development of such pres- sures emphasized. During therapy these effects emerge as great uncertainty in a patient as to whether some family episode did or did not occur and guilt about adumbrating it. Here, as so often, a key role for the therapist is to sanction the pa- tient's exploration of all the various possibilities, both those favourable to his parents and those unfavourable to them, and to encourage him to
298/362
? ? ? weigh the evidence available, whilst he (the ther- apist) remains resolutely open-minded as to where the truth may lie.
Thus far in this exposition I have not considered the critical issue of how far we can and should rely on the validity of our patients' reports. Memories are certainly fallible, and there are various occasions when an experienced therapist will rightly question the truth of what his patient is saying. What then are the criteria by which we should judge?
First, broad generalizations about the kind of parent the mother or father was and about the kind of parenting received are never to be given credence unless and until they are supported by detailed examples of how each treated the patient as a child in particular situations. For example, the glowing account of a wonderful mother may well go unsupported when detail becomes avail- able. Valid accounts of affectionate parenting not only give plenty of favourable details but are likely also to be interlaced with occasional criti- cism, so that the parent can be seen in the round. Similarly, disparaging accounts of parents in uni- formly adverse terms need close examination. In- valid accounts of either sort tend to be sweeping
299/362
? ? ? and extreme, to be either white or black. Detail is either lacking or, should it be given, is at variance with the portrait presented. By contrast, whenev- er plenty of consistent detail is given and the pic- ture that emerges conforms to what we know, from other sources, does happen in other famil- ies, and also to the known antecedents of the types of problem besetting the patient, it is ab- surd to doubt its overall validity, even if some points remain in question.
The origin of these extremes is not infrequently external pressure. For example, one parent has insisted that the child take sides with him or her against the other parent who is represented as being all bad. Or else a parent who has many shortcomings insists that he or she is above criticism.
Another occasion when a therapist is right to doubt the patient's story is when there is reason to suspect that the patient is a pathological liar. Such cases are comparatively rare and, if only for that reason, may go undetected for a time. Sooner or later, however, mounting inconsistencies and improbabilities, as well as the way the patient tells his story, engender first doubt and, later, certainty that the patient is not to be believed.
300/362
? ? ? Apart from these exceptions I believe patients' accounts are sufficiently trustworthy that a ther- apist should accept them as being reasonable ap- proximations to the truth;3 and furthermore that it is anti-therapeutic not to do so. Constantly to query the validity of the patient's story, even if only by implication, and insistence on the distort- ing role of imagination or fantasy, is the reverse of empathic. It conveys to the patient that the therapist
does not understand him and may indeed con- vince him that the therapist is behaving exactly as his parent had predicted. Thus some parents, having insisted that their child not tell of something the parent is ashamed of, may then add that, in any case, were he to do so no one would believe him.
Among the large range of adverse events and situations not so far mentioned in this lecture that a therapist should have in his mind as likely to have occurred in the life of one patient or an- other are the following:
a child may never have been wanted by one or both parents;
a child may be of the wrong sex in a family in which parents had set their hearts on a boy or a girl;
301/362
? ? ? a child may have been made the family scapegoat, sometimes as a result of a family tragedy that, with greater or less plausibility, has always been at- tributed to him;
a parent may have used guilt-inducing techniques to control a child, for example, frequent claims that the child's behaviour makes mother ill;
a parent may have sought to make one of her children her attachment fig- ure by discouraging him from exploring the world away from her and from believing that he will ever be able to make his way on his own;
a child's unusual role in a family may be the result of his mother having had an extra-marital affair during her marriage so that the child's putative father is not his real father;
another cause of a child's unusual role is when one or other parent identi- fies one child with a relative, often one of the child's grandparents, with whom he or she has had a difficult relationship, and who then re-enacts that relationship with the child;
a child may have been the target of more or less serious physical abuse from a parent or step-parent;
a child may have been involved in sexual abuse from a parent, step-par- ent, or older sibling for short or long periods of time.
For those unaware of the commoner effects on personality development of exposure to situ- ations of these kinds, a number of references are given in an Appendix to references (pp.