(1978) 'So the witch won't eat me', Boston:
Houghton
Mifflin.
A-Secure-Base-Bowlby-Johnf
How a therapist evaluates these reactions and responds to them will reflect his theoretical position.
Someone who adopts attach- ment theory will respect his patient's distress or anger about the separation and will regard them as the natural responses of someone who has be- come attached to another--a respect that will be implicit in anything he says or does.
At the same time he will give attention to the form his pa- tient's reaction takes.
If openly expressed, he will be sympathetic and may be able to ease the pa- tient's distress by giving him information about
306/362
? ? ? how he could communicate during the break. In addition, the therapist will consider how the pa- tient is construing the interruption and, should there be evidence of misconstruction, will at- tempt to discover how it may have originated. If, for example, the patient is apprehensive that the therapist will not return, the possibility of the pa- tient having been exposed to threats by a parent to abandon him might be explored. In cases where the interruption is due to the therapist be- ing unwell, he will be alert to the possibility that the patient may be apprehensive lest something he (the patient) has done or said is responsible. Were that to be so, the therapist would explore whether one of the patient's parents had sought to control him by claiming that the way he be- haved was making mother or father ill.
Similarly, should a patient react to an interrup- tion by disparaging therapy or missing a session, a therapist who adopts attachment theory would ask himself why his patient is afraid to express his feelings openly and what his childhood exper- iences may have been to account for his distrust.
It is not unlikely that the description just given of a therapist's mode of responding to his pa- tient's reactions to an interruption will contrast
307/362
? ? ? with that of a therapist who adopts and applies one or another of the traditional psychoanalytic theories. For example, one such therapist might regard his patient's reactions as being rather childish, even infantile, and as indicating that the patient was fixated in an oral or a symbiotic phase. What the therapist then might say, and es- pecially the way he might say it, could well be ex- perienced by the patient as lacking in respect for his (the patient's) current feelings of attachment, distress, or anger. Here again there would be danger that the therapist might appear to be re- sponding in a cold unsympathetic way and all too like one or other of the patient's parents. Were that so the exchange would be anti-therapeutic.
How far a therapist can wisely go in meeting a patient's desire to keep in communication during breaks, e. g. by telephone, and for comforting when distressed during a session, turns on many personal factors in their relationship. On the one hand, there is danger of the therapist's appearing to lack sympathy for the patient's distress or even to seem rejecting. On the other is the risk of his appearing to offer more than he is prepared to give. There are occasions when it would be inhu- man not to allow a distressed patient to make
308/362
? ? ? some form of physical contact: the roles are then explicitly comforter and comforted. Yet there is always danger that physical contact can elicit sexual feelings, especially when sexes are differ- ent. Depending on the situation each therapist must make his own decisions and draw his own lines. The more alive to such issues a therapist is the better will he be able to avoid the pitfalls.
EMOTIONAL COMMUNICATIONS AND THE RESTRUCTURING OF WORKING MODELS
When a therapist utilizes the kind of technique advocated here, it can sometimes happen that therapy gets into a rut in which the patient per- sists endlessly in describing what a terrible time he had as a child and how badly his parents treated him, without any progress being made. One cause of such perseveration, I suspect, is that the patient is convinced that his therapist does not accept the truth of what he is saying: hence his endless repetition of it. This may be due to the patient having always been scoffed at by those to whom he has told the story in the past or, and perhaps more commonly, to the therapist himself having indicated scepticism or disbelief. This can be done in a myriad of ways, by tone of voice, by
309/362
? ? ? querying the details, by failing to attach any par- ticular weight to what the patient describes.
Evidently when the problem lies in the therap- ist's incredulity the way out is for him to make it plain that he knows all too well that such things do happen to children and has no reason to doubt the patient's account. Even so the impasse may continue: the story is told and retold in a flat cyn- ical way with no show of feeling whatever.
This situation has been discussed by Selma Fraiberg who, with colleagues, set out to help vul- nerable mothers at risk of either neglecting or ab- using their infants (Fraiberg, Adelson, and Sha- piro, 1975). They describe making visits to the homes of two such mothers and listening to the distressing tales these women had to tell. Each told a story of gross cruelty during child- hood--being subjected to violent beatings, being locked out in the cold, often deserted by mother, being shunted from one place to another, and of having no one to go to for help or comfort. Neither gave a hint of how they might have felt nor what they may have felt like doing. One, a girl of 16 who avoided touching or holding her baby (who screamed hopelessly), insisted: 'But what's the use of talking? I always kept things to myself.
310/362
? ? ? I want to forget. I don't want to think. ' This was the point at which the therapist intervened--by herself expressing all the feelings that any and every child would be expected to have in the situ- ations described: how frightened, how angry, how hopeless one would feel, and also how one would long to go to someone who would understand and provide comfort and protection. In doing so the therapist not only showed an understanding of how the patient must have felt, but communic- ated in her manner that the expression of such feeling and desire would be met with a sympath- etic and comforting response. Only then was it possible for the young mother to express all the grief, the tears, 'and the unspeakable anguish for herself as a cast-off child' that she had always felt but had never dared express.
In this account of Fraiberg's methods of help- ing a patient express the emotions she dares not show I have deliberately emphasized the link between emotion and action. Failure to express emotion is due very largely to unconscious fear lest the action of which the emotion is a part will lead to a dreaded outcome. In many families an- ger with an adult leads to punishment which can sometimes be severe. Moreover a tearful appeal
311/362
? ? ? for comfort and help can lead to rejection and hu- miliation. It is perhaps too often forgotten by clinicians that many children, when they become distressed and weepy and are looking for com- fort, are shooed off as intolerable little cry-babies. Instead of the comforting provided by an under- standing and affectionate parent, these children meet with an unsympathetic and critical rebuff. No wonder therefore if, should this pattern pre- vail during childhood, the child learns never to show distress or seek comfort and, should he un- dertake therapy, assumes that his therapist will be as intolerant of anger and tears as his parents always were.
Every therapist who adopts a psychoanalytic per- spective has long recognized that, to be effective, therapy requires that a patient not only talks about his memories, his ideas and dreams, his hopes and desires, but also expresses his feelings. The discussion of Fraiberg's technique for help- ing a cynical and frozen young woman to discover the depth of her feelings and to express them freely to her therapist is therefore a fitting note on which to end. In writing this lecture I have throughout been aware that, by using terms such as 'information', 'communication', and 'working
312/362
? ? ? models', it would be easy for an unwary reader to suppose that these terms belong within a psycho- logy concerned only with cognition and one bereft of feeling and action. Although for many years it was all too common for cognitive psycho- logists to omit reference to emotion, it is now re- cognized that to do so is artificial and unfruitful (Hinde, Perret-Clermont, and Stevenson-Hinde, 1985). There are, in fact, no more important com- munications between one human being and an- other than those expressed emotionally, and no information more vital for constructing and re- constructing working models of self and other than information about how each feels towards the other. During the earliest years of our lives, indeed, emotional expression and its reception are the only means of communication we have, so that the foundations of our working models of self and attachment figure are perforce laid using information from that source alone. Small won- der therefore, if, in reviewing his attachment re- lationships during the course of psychotherapy and restructuring his working models, it is the emotional communications between a patient and his therapist that play the crucial part.
313/362
? ? ? 1 Within traditional theory this shift of role by a pa- tient is likely to be termed a case of identification with the aggressor.
2 Since in previous publications I have given much at- tention to the ill effects on personality development of bereavements and prolonged separations, these themes are omitted from what follows.
3 For research purposes, however, criteria for accept- ing retrospective information as valid must be much stricter.
REFERENCES
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Ainsworth, M. D. (1962) 'The effects of maternal deprivation: a review of findings and controversy in the context of research strategy' in: Deprivation of maternal care: a reassessment of its effects, Public Health Papers no. 14, Geneva: World Health Organisation.
Ainsworth, M. D. (1963) 'The development of infant- mother interaction among the Ganda' in B. M. Foss (ed. ) Determinants of infant behaviour, vol. 2, London: Methuen; New York: Wiley.
Ainsworth, M. D. S. (1967) Infancy in Uganda: infant care and the growth of attachment, Baltimore: Johns Hopkins University Press.
Ainsworth, M. D. S. (1969) 'Object relations, depend- ency and attachment: a theoretical review of the infant-mother relationship', Child Development, 40: 969-1025.
Ainsworth, M. D. S. (1977) 'Social development in the first year of life: maternal influences on infant- mother attachment' in J. M. Tanner (ed. ) Develop- ments in psychiatric research, London: Tavistock.
Ainsworth, M. D. S. (1982) 'Attachment: retrospect and prospect' in C. M. Parkes and J. Stevenson-Hinde
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? ? ? (eds) The place of attachment in human behavior,
3-30, New York: Basic Books; London: Tavistock. Ainsworth, M. D. S. (1985) 'I Patterns of infant-mother attachment: antecedents and effects on develop- ment' and 'II Attachments across the life-span', Bulletin of New York Academy of Medicine, 61:
771-91 and 791-812.
Ainsworth, M. D. S. and Wittig, B. A. (1969) 'Attachment
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Ainsworth, M. D. S. , Bell, S. M. , and Stayton, D. J. (1971) 'Individual differences in strange situation behavi- or of one-year-olds' in H. R. Schaffer (ed. ) The ori- gins of human social relations, 17-57, London: Academic Press.
Ainsworth, M. D. , Blehar, M. C. , Waters, E. , and Wall, S. (1978) Patterns of attachment: assessed in the strange situation and at home, Hillsdale, NJ: Lawrence Erlbaum.
Anderson, J. W. (1972) 'Attachment behaviour out of doors' in N. Blurton Jones (ed). Ethological stud- ies of child behaviour, Cambridge: Cambridge University Press.
Arend, R. , Gove, F. L. , and Sroufe, L. A. (1979) 'Continu- ity of individual adaptation from infancy to kindergarten: a predictive study of ego-resiliency
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Brown, G. W. and Harris, T. (1978) The social origins of depression, London:Tavistock.
Burlingham, D. and Freud, A. (1942) Young children in war-time London, London: Allen & Unwin.
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Cassidy, J. and Kobak, R. (1988) 'Avoidance and its re- lation to other defensive processes' in J. Belsky and T. Nezworski (eds) Clinical Implications of Attachment, Hillsdale, NJ: Lawrence Erlbaum.
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of a controversy, London: McGraw-Hill.
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Fairbairn, W. R. D. (1940) 'Schizoid factors in the per- sonality' in Psychoanalytic studies of the
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Aggression and anti-social behaviour in children and adolescents, 73-93, Oxford and New York: Pergamon Press.
Feinstein, H. M. , Paul, N. , and Pettison, E. (1964) 'Group therapy for mothers with infanticidal im- pulses', American Journal of Psychiatry, 120: 882-6.
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Frommer, E. A. and O'Shea, G. (1973) 'Antenatal identi- fication of women liable to have problems in man- aging their infants', British Journal of Psychiatry, 123, 149-56.
Furman, E. (1974) A child's parent dies, New Haven and London: Yale University Press.
Gaensbauer, T. J. and Sands, K. (1979) 'Distorted af- fective communications in abused/neglected in- fants and their potential impact on caretakers', Journal of the American Academy of Child Psy- chiatry, 18: 236-50.
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? ? ? Gedo, J. E. (1979) Beyond interpretation: toward a re- vised theory for psychoanalysis, New York: Inter- national Universities Press.
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Gill, H. S.
306/362
? ? ? how he could communicate during the break. In addition, the therapist will consider how the pa- tient is construing the interruption and, should there be evidence of misconstruction, will at- tempt to discover how it may have originated. If, for example, the patient is apprehensive that the therapist will not return, the possibility of the pa- tient having been exposed to threats by a parent to abandon him might be explored. In cases where the interruption is due to the therapist be- ing unwell, he will be alert to the possibility that the patient may be apprehensive lest something he (the patient) has done or said is responsible. Were that to be so, the therapist would explore whether one of the patient's parents had sought to control him by claiming that the way he be- haved was making mother or father ill.
Similarly, should a patient react to an interrup- tion by disparaging therapy or missing a session, a therapist who adopts attachment theory would ask himself why his patient is afraid to express his feelings openly and what his childhood exper- iences may have been to account for his distrust.
It is not unlikely that the description just given of a therapist's mode of responding to his pa- tient's reactions to an interruption will contrast
307/362
? ? ? with that of a therapist who adopts and applies one or another of the traditional psychoanalytic theories. For example, one such therapist might regard his patient's reactions as being rather childish, even infantile, and as indicating that the patient was fixated in an oral or a symbiotic phase. What the therapist then might say, and es- pecially the way he might say it, could well be ex- perienced by the patient as lacking in respect for his (the patient's) current feelings of attachment, distress, or anger. Here again there would be danger that the therapist might appear to be re- sponding in a cold unsympathetic way and all too like one or other of the patient's parents. Were that so the exchange would be anti-therapeutic.
How far a therapist can wisely go in meeting a patient's desire to keep in communication during breaks, e. g. by telephone, and for comforting when distressed during a session, turns on many personal factors in their relationship. On the one hand, there is danger of the therapist's appearing to lack sympathy for the patient's distress or even to seem rejecting. On the other is the risk of his appearing to offer more than he is prepared to give. There are occasions when it would be inhu- man not to allow a distressed patient to make
308/362
? ? ? some form of physical contact: the roles are then explicitly comforter and comforted. Yet there is always danger that physical contact can elicit sexual feelings, especially when sexes are differ- ent. Depending on the situation each therapist must make his own decisions and draw his own lines. The more alive to such issues a therapist is the better will he be able to avoid the pitfalls.
EMOTIONAL COMMUNICATIONS AND THE RESTRUCTURING OF WORKING MODELS
When a therapist utilizes the kind of technique advocated here, it can sometimes happen that therapy gets into a rut in which the patient per- sists endlessly in describing what a terrible time he had as a child and how badly his parents treated him, without any progress being made. One cause of such perseveration, I suspect, is that the patient is convinced that his therapist does not accept the truth of what he is saying: hence his endless repetition of it. This may be due to the patient having always been scoffed at by those to whom he has told the story in the past or, and perhaps more commonly, to the therapist himself having indicated scepticism or disbelief. This can be done in a myriad of ways, by tone of voice, by
309/362
? ? ? querying the details, by failing to attach any par- ticular weight to what the patient describes.
Evidently when the problem lies in the therap- ist's incredulity the way out is for him to make it plain that he knows all too well that such things do happen to children and has no reason to doubt the patient's account. Even so the impasse may continue: the story is told and retold in a flat cyn- ical way with no show of feeling whatever.
This situation has been discussed by Selma Fraiberg who, with colleagues, set out to help vul- nerable mothers at risk of either neglecting or ab- using their infants (Fraiberg, Adelson, and Sha- piro, 1975). They describe making visits to the homes of two such mothers and listening to the distressing tales these women had to tell. Each told a story of gross cruelty during child- hood--being subjected to violent beatings, being locked out in the cold, often deserted by mother, being shunted from one place to another, and of having no one to go to for help or comfort. Neither gave a hint of how they might have felt nor what they may have felt like doing. One, a girl of 16 who avoided touching or holding her baby (who screamed hopelessly), insisted: 'But what's the use of talking? I always kept things to myself.
310/362
? ? ? I want to forget. I don't want to think. ' This was the point at which the therapist intervened--by herself expressing all the feelings that any and every child would be expected to have in the situ- ations described: how frightened, how angry, how hopeless one would feel, and also how one would long to go to someone who would understand and provide comfort and protection. In doing so the therapist not only showed an understanding of how the patient must have felt, but communic- ated in her manner that the expression of such feeling and desire would be met with a sympath- etic and comforting response. Only then was it possible for the young mother to express all the grief, the tears, 'and the unspeakable anguish for herself as a cast-off child' that she had always felt but had never dared express.
In this account of Fraiberg's methods of help- ing a patient express the emotions she dares not show I have deliberately emphasized the link between emotion and action. Failure to express emotion is due very largely to unconscious fear lest the action of which the emotion is a part will lead to a dreaded outcome. In many families an- ger with an adult leads to punishment which can sometimes be severe. Moreover a tearful appeal
311/362
? ? ? for comfort and help can lead to rejection and hu- miliation. It is perhaps too often forgotten by clinicians that many children, when they become distressed and weepy and are looking for com- fort, are shooed off as intolerable little cry-babies. Instead of the comforting provided by an under- standing and affectionate parent, these children meet with an unsympathetic and critical rebuff. No wonder therefore if, should this pattern pre- vail during childhood, the child learns never to show distress or seek comfort and, should he un- dertake therapy, assumes that his therapist will be as intolerant of anger and tears as his parents always were.
Every therapist who adopts a psychoanalytic per- spective has long recognized that, to be effective, therapy requires that a patient not only talks about his memories, his ideas and dreams, his hopes and desires, but also expresses his feelings. The discussion of Fraiberg's technique for help- ing a cynical and frozen young woman to discover the depth of her feelings and to express them freely to her therapist is therefore a fitting note on which to end. In writing this lecture I have throughout been aware that, by using terms such as 'information', 'communication', and 'working
312/362
? ? ? models', it would be easy for an unwary reader to suppose that these terms belong within a psycho- logy concerned only with cognition and one bereft of feeling and action. Although for many years it was all too common for cognitive psycho- logists to omit reference to emotion, it is now re- cognized that to do so is artificial and unfruitful (Hinde, Perret-Clermont, and Stevenson-Hinde, 1985). There are, in fact, no more important com- munications between one human being and an- other than those expressed emotionally, and no information more vital for constructing and re- constructing working models of self and other than information about how each feels towards the other. During the earliest years of our lives, indeed, emotional expression and its reception are the only means of communication we have, so that the foundations of our working models of self and attachment figure are perforce laid using information from that source alone. Small won- der therefore, if, in reviewing his attachment re- lationships during the course of psychotherapy and restructuring his working models, it is the emotional communications between a patient and his therapist that play the crucial part.
313/362
? ? ? 1 Within traditional theory this shift of role by a pa- tient is likely to be termed a case of identification with the aggressor.
2 Since in previous publications I have given much at- tention to the ill effects on personality development of bereavements and prolonged separations, these themes are omitted from what follows.
3 For research purposes, however, criteria for accept- ing retrospective information as valid must be much stricter.
REFERENCES
Adams-Tucker, C. (1982) 'Proximate effects of sexual abuse in childhood: a report on 28 children', American Journal of Psychiatry, 139: 1252-6.
Ainsworth, M. D. (1962) 'The effects of maternal deprivation: a review of findings and controversy in the context of research strategy' in: Deprivation of maternal care: a reassessment of its effects, Public Health Papers no. 14, Geneva: World Health Organisation.
Ainsworth, M. D. (1963) 'The development of infant- mother interaction among the Ganda' in B. M. Foss (ed. ) Determinants of infant behaviour, vol. 2, London: Methuen; New York: Wiley.
Ainsworth, M. D. S. (1967) Infancy in Uganda: infant care and the growth of attachment, Baltimore: Johns Hopkins University Press.
Ainsworth, M. D. S. (1969) 'Object relations, depend- ency and attachment: a theoretical review of the infant-mother relationship', Child Development, 40: 969-1025.
Ainsworth, M. D. S. (1977) 'Social development in the first year of life: maternal influences on infant- mother attachment' in J. M. Tanner (ed. ) Develop- ments in psychiatric research, London: Tavistock.
Ainsworth, M. D. S. (1982) 'Attachment: retrospect and prospect' in C. M. Parkes and J. Stevenson-Hinde
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