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.
A-Secure-Base-Bowlby-Johnf
As Bloch (1978) has put it, a ba- sic premise of the therapeutic approach she and others like her advocate for these cases is that what is so facilely dubbed as fantasy be
239/362
? ? ? recognized as a reflection of a grim reality, and that an early therapeutic task is to identify the real-life experiences lying close behind the de- ceptive camouflage.
Not only are the childhood experiences of these nearpsychotic children the same as those be- lieved characteristic of adult patients with mul- tiple personality, but the states of mind described by the respective therapists have features strik- ingly similar too. It seems highly likely therefore that the two conditions are closely related. It should be noted furthermore that these findings give support to the hypothesis advanced by Niederland (1959a and b, discussed by Bowlby, 1973) that the paranoid delusions of Judge Schreber, on which Freud based his theory of paranoia, were distorted versions of the ex- traordinary pedagogic regime to which the pa- tient's father had subjected him from the early months of life.
In this contribution, as in almost all my work, I have focused attention on psychopathology and some of the conditions that give rise to it. My reason for doing so is the belief that only with a better understanding of aetiology and psycho- pathology will it be possible to develop
240/362
? ? ? therapeutic techniques and, more especially, pre- ventive measures that will be at once effective and economical in skilled manpower.
My therapeutic approach is far from original. The basic hypothesis can be stated simply. So long as current modes of perceiving and constru- ing situations, and the feelings and actions that ensue therefrom, are determined by emotionally significant events and experiences that have be- come shut away from further conscious pro- cessing, the personality will be prone to cogni- tion, affect, and behaviour maladapted to the cur- rent situation. When yearning for love and care is shut away, it will continue to be inaccessible. When there is anger, it will continue to be direc- ted at inappropriate targets. Similarly anxiety will continue to be aroused by inappropriate situ- ations and hostile behaviour be expected from in- appropriate sources. The therapeutic task is therefore to help the patient discover what these events and experiences may have been so that the thoughts, feelings, and behaviour that the situ- ations arouse, and that continue to be so trouble- some, can be linked again to the situations that aroused them. Then the true targets of his yearn- ing and anger and the true sources of his anxiety
241/362
? ? ? and fear will become plain. Not only will such discoveries show that his modes of cognition, feeling, and behaviour are far more intelligible, given the circumstances in which they originated, than they had seemed before but, once the pa- tient has grasped how and why he is responding as he is, he will be in a position to reappraise his responses and, should he wish, to undertake their radical restructuring. Since such reappraisal and re-structuring can be achieved only by the patient himself, the emphasis in this formulation of the therapist's task is on helping the patient first to discover for himself what the relevant scenes and experiences probably were and secondly to spend time pondering on how they have continued to influence him. Only then will he be in a position to undertake the reorganization of his modes of construing the world, thinking about it, and act- ing in it which are called for.
The concepts of therapeutic process outlined here are similar to those described in much great- er detail by others. Examples are publications by Peterfreund (1983) and by Guidano and Liotti (1983). Although the authors of these two books started their therapeutic work from radically dif- ferent positions, namely traditional versions of
242/362
? ? ? psychoanalysis and of behaviour therapy respect- ively, the principles that now guide their work show a striking convergence. Similarly current forms of bereavement therapy, which focus on distressing events in the comparatively recent past, are found to be based on the very same principles, even when developed within equally different traditions (Raphael, 1977; Melges and DeMaso, 1980). However divergent tactics may still appear, strategic thinking is on a convergent course.
1 A long abstract of McCann's account is given in Loss (Bowlby, 1980, 338-44).
2 See also Bliss (1986). Further evidence that multiple personality disorder develops during childhood as a
defence against overwhelming trauma, usually severe abuse, is reported in Kluft (1985).
7
THE ROLE OF ATTACHMENT IN PERSONALITY DEVELOPMENT
Evidence regarding the role of attachment in personality development has been accumulating apace during the 1980s. Earlier findings have been replicated on samples of diverse origin; methods of observation have been refined and new methods introduced; and the role of easy two-way communication between parent and child in making for healthy emotional develop- ment has been emphasized. Since I believe this new work to have far-reaching clinical implica- tions, my aim in this lecture has been to present a review of these findings in a form suited to those working as psychotherapists in the mental health field.
For the convenience of the reader I begin by restating in summary form some of the features most distinctive of attachment theory.
? 244/362
? ? ? SOME DISTINCTIVE FEATURES OF ATTACHMENT THEORY
It will be remembered that attachment theory was formulated to explain certain patterns of be- haviour, characteristic not only of infants and young children but also adolescents and adults, that were formerly conceptualized in terms of de- pendency and over-dependency. In its original formulation observations of how young children respond when placed in a strange place with strange people, and the effects such experiences have on a child's subsequent relations with his parents, were especially influential. In all sub- sequent work theory has continued to be tied closely to detailed observations and interview data of how individuals respond in particular situations. Historically the theory was developed out of the object-relations tradition in psychoana- lysis; but it has drawn also on concepts from evolution theory, ethology, control theory, and cognitive psychology. One result is the reformula- tion of psychoanalytic metapsychology in ways compatible with modern biology and psychology and in conformity with the commonly accepted criteria of natural science (see Lecture 4).
Attachment theory emphasizes:
245/362
? ? ? (a) the primary status and biological function of intimate emotional bonds between individuals, the making and maintaining of which are postulated to be controlled by a cybernetic system situated within the central nervous system, utilizing working models of self and attachment figure in relation- ship with each other. 1
(b) the powerful influence on a child's development of the ways he is treated by his parents, especially his mother-figure, and
(c) that present knowledge of infant and child development requires that a theory of developmental pathways should replace theories that invoke specific phases of development in which it is held a person may become fixated and/or to which he may regress.
THE PRIMACY OF INTIMATE EMOTIONAL BONDS
Attachment theory regards the propensity to make intimate emotional bonds to particular in- dividuals as a basic component of human nature, already present in germinal form in the neonate and continuing through adult life into old age. During infancy and childhood bonds are with parents (or parent substitutes) who are looked to for protection, comfort, and support. During healthy adolescence and adult life these bonds persist, but are complemented by new bonds, commonly of a heterosexual nature. Although food and sex sometimes play important roles in attachment relationships, the relationship exists in its own right and has a key survival function of its own, namely protection. Initially the only means of communication between infant and
246/362
? ? ? mother is through emotional expression and its accompanying behaviour. Although supplemen- ted later by speech, emotionally mediated com- munication nonetheless persists as a principal feature of intimate relationships throughout life.
Within the attachment framework therefore in- timate emotional bonds are seen as neither sub- ordinate to nor derivative from food and sex. Nor is the urgent desire for comfort and support in adversity regarded as childish, as dependency theory implies. Instead the capacity to make in- timate emotional bonds with other individuals, sometimes in the careseeking role and sometimes in the caregiving one, is regarded as a principal feature of effective personality functioning and mental health.
As a rule careseeking is shown by a weaker and less experienced individual towards someone re- garded as stronger and/or wiser. A child, or older person in the careseeking role, keeps within range of the caregiver, the degree of closeness or of ready accessibility depending on circum- stances: hence the concept of attachment behaviour.
Caregiving, the major role of parents and com- plementary to attachment behaviour, is regarded
247/362
? ? ? in the same light as careseeking, namely as a ba- sic component of human nature (see Lecture 1).
Exploring the environment, including play and varied activities with peers, is seen as a third ba- sic component and one antithetic to attachment behaviour. When an individual (of any age) is feeling secure he is likely to explore away from his attachment figure. When alarmed, anxious, tired, or unwell he feels an urge towards proxim- ity. Thus we see the typical pattern of interaction between child and parent known as exploration from a secure base, first described by Ainsworth (1967). Provided the parent is known to be ac- cessible and will be responsive when called upon, a healthy child feels secure enough to explore. At first these explorations are limited both in time and space. Around the middle of the third year, however, a secure child begins to become confid- ent enough to increase time and distance away--first to half-days and later to whole days. As he grows into adolescence, his excursions are extended to weeks or months, but a secure home base remains indispensable nonetheless for op- timal functioning and mental health. Note that the concept of secure base is a central feature of the theory of psychotherapy proposed.
248/362
? ? ? During the early months of life an infant shows many of the component responses of what will later become attachment behaviour, but the or- ganized pattern does not develop until the second half of the first year. From birth onwards he shows a germinal capacity to engage in social in- teraction and pleasure in doing so (Stern, 1985): thus there is no autistic or narcissistic phase. Within days, moreover, he is able to distinguish between his mother-figure and others by means of her smell and by hearing her voice, and also by the way she holds him. Visual discrimination is not reliable until the second quarter. Initially cry- ing is the only means available to him for sig- nalling his need for care, and contentment the only means for signalling that he has been satis- fied. During the second month, however, his so- cial smile acts strongly to encourage his mother in her ministrations and his repertoire of emo- tional communications rapidly extends (Izard, 1982; Emde, 1983).
The development of attachment behaviour as an organized system, having as its goal the keep- ing of proximity or of accessibility to a discriminated mother-figure, requires that the child should have developed the cognitive
249/362
? ? ? capacity to keep his mother in mind when she is not present: this capacity develops during the second six months of life. Thus from nine months onwards the great majority of infants respond to being left with a strange person by protest and crying, and also by more or less prolonged fret- ting and rejection of the stranger. These observa- tions demonstrate that during these months an infant is becoming capable of representation and that his working model of his mother is becoming available to him for purposes of comparison dur- ing her absence and for recognition after her re- turn. Complementary to his model of his mother, he develops a working model of himself in inter- action with her, likewise for father.
A major feature of attachment theory is the hy- pothesis that attachment behaviour is organized by means of a control system within the central nervous system, analogous to the physiological control systems that maintain physiological measures such as blood pressure and body tem- perature within set limits. Thus the theory pro- poses that, in a way analogous to physiological homeostasis, the attachment control system maintains a person's relation to his attachment figure between certain limits of distance and
250/362
? ? ? accessibility, using increasingly sophisticated methods of communication for doing so. As such, the effects of its operation can be regarded as an example of what can usefully be termed environ- mental homeostasis (Bowlby, 1969, 1982). By postulating a control system of this sort (with analogous systems controlling other forms of be- haviour) attachment theory contains within itself a theory of motivation that can replace traditional theories which invoke a postulated build-up of energy or drive. Among several advantages of control theory are that it gives as much attention to the conditions terminating a behavioural se- quence as to those initiating it and is proving a fruitful framework for empirical research.
The presence of an attachment control system and its linkage to the working models of self and attachment figure(s) that are built in the mind during childhood are held to be central features of personality functioning throughout life.
PATTERNS OF ATTACHMENT AND CONDITIONS DETERMINING THEIR DEVELOPMENT
The second area to which attachment theory pays special attention is the role of a child's parents in determining how he develops. There is today
251/362
? ? ? impressive and mounting evidence that the pat- tern of attachment that an individual develops during the years of immaturity--infancy, child- hood, and adolescence--is profoundly influenced by the way his parents (or other parent figures) treat him. This evidence derives from a number of systematic research studies, the most impress- ive being prospective studies of socio-emotional development during the first five years under- taken by developmental psychologists who are also clinically sophisticated. Pioneered by Ainsworth (Ainsworth, Blehar, Waters, and Wall, 1978; Ainsworth, 1985) and expanded, notably by Main (Main, Kaplan, and Cassidy, 1985) and Sroufe (1983, 1985) in the United States and by Grossmann (Grossmann, Grossmann, and Sch- wan, 1986) in Germany, these studies are now multiplying fast. Their findings are remarkably consistent and have the clearest of clinical significance.
Three principal patterns of attachment, first described by Ainsworth and her colleagues in 1971, are now reliably identified, together with the family conditions that promote them. These are first the pattern of secure attachment in which the individual is confident that his parent
252/362
? ? ? (or parent figure) will be available, responsive, and helpful should he encounter adverse or frightening situations. With this assurance, he feels bold in his explorations of the world. This pattern is promoted by a parent, in the early years especially by mother, being readily avail- able, sensitive to her child's signals, and lovingly responsive when he seeks protection and/or comfort.
A second pattern is that of anxious resistant at- tachment in which the individual is uncertain whether his parent will be available or responsive or helpful when called upon. Because of this un- certainty he is always prone to separation anxi- ety, tends to be clinging, and is anxious about ex- ploring the world. This pattern, in which conflict is evident, is promoted by a parent being avail- able and helpful on some occasions but not on others, and by separations and, as clinical find- ings show, by threats of abandonment used as a means of control.
A third pattern is that of anxious avoidant at- tachment in which the individual has no confid- ence that, when he seeks care, he will be respon- ded to helpfully but, on the contrary, expects to be rebuffed. When in marked degree such an
253/362
? ? ? individual attempts to live his life without the love and support of others, he tries to become emotionally self-sufficient and may later be dia- gnosed as narcissistic or as having a false self of the type described by Winnicott (1960). This pat- tern, in which conflict is more hidden, is the res- ult of the individual's mother constantly rebuff- ing him when he approaches her for comfort or protection. The most extreme cases result from repeated rejections.
Although in most cases the pattern observed conforms fairly closely to one or another of the three well-recognized types, there have been puzzling exceptions. During the assessment pro- cedure used in these studies (the Ainsworth Strange Situation), in which infant and mother are observed in interaction during a series of brief episodes, certain infants have appeared to be disoriented and/or disorganized. One infant appears dazed; another freezes immobile; a third engages in some stereotypy; a fourth starts a movement, then stops unaccountably. After much study Main and her colleagues have con- cluded that these peculiar forms of behaviour oc- cur in infants who are exhibiting a disorganized version of one of the three typical patterns, more
254/362
? ? ? often than not the anxious resistant one (Main and Weston, 1981; Main and Solomon, 1990). Some instances are seen in infants known to have been physically abused and/or grossly neglected by the parent (Crittenden, 1985). Others occur in dyads in which the mother is suffering from a severe form of bipolar affective illness and who treats her child in an erratic and unpredictable way (Radke-Yarrow et al. , 1985). Yet others are shown by the infants of mothers who are still pre- occupied with mourning a parental figure lost during the mother's childhood and by those of mothers who themselves suffered physical or sexual abuse as children (Main and Hesse, 1990). Cases showing these deviant patterns are clearly of great clinical concern, and much attention is now being given to them.
Knowledge of the origins of these deviant pat- terns confirms in the clearest possible way the in- fluence on a child's pattern of attachment of the parent's way of treating his or her child. Yet fur- ther confirmatory evidence comes from detailed observations of the way different mothers treat their children during a laboratory session ar- ranged when the child is 21/2 years old (Matas, Arend, and Sroufe, 1978). In this study the child
255/362
? ? ? is given a small but difficult task for the solution of which he requires a little assistance, and his mother is free to interact with him. In this situ- ation, it is found, the way she treats him correl- ates closely with the pattern of attachment her child showed towards her 18 months earlier. Thus the mother of a child earlier assessed as se- curely attached is found to be attentive and sens- itive to his performance and to respond to his successes and difficulties in a way that is helpful and encouraging. Conversely the mother of a child earlier assessed as insecure is found to be less attentive and/or less sensitive. In some cases her responses are ill-timed and unhelpful; in oth- ers she may take little notice of what he is doing or how he is feeling; in yet others she may act- ively discourage or reject his bids for help and en- couragement. Note that the pattern of interaction adopted by the mother of a secure infant provides an excellent model for the pattern of therapeutic intervention advocated here.
In thus underlining the very great influence that a child's mother has on his development, it is necessary also to consider what has led a mother to adopt the style of mothering she does. One ma- jor influence on this is the amount of emotional
256/362
? ? ? support, or lack of it, she herself is receiving at the time. Another is the form of mothering that she herself received when a child. Once these factors are recognized, as they have been by many analytically oriented clinicians long since, the idea of blaming parents evaporates and is re- placed by a therapeutic approach. Since the emo- tional problems of parents stemming from the past and their effects on children has now be- come a field for systematic research, a brief de- scription of current work is given at the end of Lecture 8.
PERSISTENCE OF PATTERNS
If we return now to the patterns of attachment observed in one-year-olds, prospective studies show that each pattern of attachment, once de- veloped, tends to persist. One reason for this is that the way a parent treats a child, whether for better or for worse, tends to continue unchanged. Another is that each pattern tends to be self-per- petuating. Thus a secure child is a happier and more rewarding child to care for and also is less demanding than an anxious one. An anxious am- bivalent child is apt to be whiny and clinging; whilst an anxious avoidant child keeps his
257/362
? ? ? distance and is prone to bully other children. In both of these last cases the child's behaviour is likely to elicit an unfavourable response from the parent so that vicious circles develop.
Although for these reasons patterns, once formed, are apt to persist, this is by no means ne- cessarily so. Evidence shows that during the first two or three years the pattern of attachment is a property of the relationship, for example, child to mother or child to father, and that if the parent treats the child differently the pattern will change accordingly. These changes are amongst much evidence reviewed by Sroufe (1985) that stability of pattern, when it occurs, cannot be attributed to the child's inborn temperament as has sometimes been claimed. Nevertheless, as a child grows older, the pattern becomes increasingly a prop- erty of the child himself, which means that he tends to impose it, or some derivative of it, upon new relationships such as with a teacher, a foster- mother, or a therapist.
The results of this process of internalization are evident in a prospective study which shows that the pattern of attachment characteristic of a mother-child pair, as assessed when the child is aged 12 months, is highly predictive of how that
258/362
? ? ? 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.
239/362
? ? ? recognized as a reflection of a grim reality, and that an early therapeutic task is to identify the real-life experiences lying close behind the de- ceptive camouflage.
Not only are the childhood experiences of these nearpsychotic children the same as those be- lieved characteristic of adult patients with mul- tiple personality, but the states of mind described by the respective therapists have features strik- ingly similar too. It seems highly likely therefore that the two conditions are closely related. It should be noted furthermore that these findings give support to the hypothesis advanced by Niederland (1959a and b, discussed by Bowlby, 1973) that the paranoid delusions of Judge Schreber, on which Freud based his theory of paranoia, were distorted versions of the ex- traordinary pedagogic regime to which the pa- tient's father had subjected him from the early months of life.
In this contribution, as in almost all my work, I have focused attention on psychopathology and some of the conditions that give rise to it. My reason for doing so is the belief that only with a better understanding of aetiology and psycho- pathology will it be possible to develop
240/362
? ? ? therapeutic techniques and, more especially, pre- ventive measures that will be at once effective and economical in skilled manpower.
My therapeutic approach is far from original. The basic hypothesis can be stated simply. So long as current modes of perceiving and constru- ing situations, and the feelings and actions that ensue therefrom, are determined by emotionally significant events and experiences that have be- come shut away from further conscious pro- cessing, the personality will be prone to cogni- tion, affect, and behaviour maladapted to the cur- rent situation. When yearning for love and care is shut away, it will continue to be inaccessible. When there is anger, it will continue to be direc- ted at inappropriate targets. Similarly anxiety will continue to be aroused by inappropriate situ- ations and hostile behaviour be expected from in- appropriate sources. The therapeutic task is therefore to help the patient discover what these events and experiences may have been so that the thoughts, feelings, and behaviour that the situ- ations arouse, and that continue to be so trouble- some, can be linked again to the situations that aroused them. Then the true targets of his yearn- ing and anger and the true sources of his anxiety
241/362
? ? ? and fear will become plain. Not only will such discoveries show that his modes of cognition, feeling, and behaviour are far more intelligible, given the circumstances in which they originated, than they had seemed before but, once the pa- tient has grasped how and why he is responding as he is, he will be in a position to reappraise his responses and, should he wish, to undertake their radical restructuring. Since such reappraisal and re-structuring can be achieved only by the patient himself, the emphasis in this formulation of the therapist's task is on helping the patient first to discover for himself what the relevant scenes and experiences probably were and secondly to spend time pondering on how they have continued to influence him. Only then will he be in a position to undertake the reorganization of his modes of construing the world, thinking about it, and act- ing in it which are called for.
The concepts of therapeutic process outlined here are similar to those described in much great- er detail by others. Examples are publications by Peterfreund (1983) and by Guidano and Liotti (1983). Although the authors of these two books started their therapeutic work from radically dif- ferent positions, namely traditional versions of
242/362
? ? ? psychoanalysis and of behaviour therapy respect- ively, the principles that now guide their work show a striking convergence. Similarly current forms of bereavement therapy, which focus on distressing events in the comparatively recent past, are found to be based on the very same principles, even when developed within equally different traditions (Raphael, 1977; Melges and DeMaso, 1980). However divergent tactics may still appear, strategic thinking is on a convergent course.
1 A long abstract of McCann's account is given in Loss (Bowlby, 1980, 338-44).
2 See also Bliss (1986). Further evidence that multiple personality disorder develops during childhood as a
defence against overwhelming trauma, usually severe abuse, is reported in Kluft (1985).
7
THE ROLE OF ATTACHMENT IN PERSONALITY DEVELOPMENT
Evidence regarding the role of attachment in personality development has been accumulating apace during the 1980s. Earlier findings have been replicated on samples of diverse origin; methods of observation have been refined and new methods introduced; and the role of easy two-way communication between parent and child in making for healthy emotional develop- ment has been emphasized. Since I believe this new work to have far-reaching clinical implica- tions, my aim in this lecture has been to present a review of these findings in a form suited to those working as psychotherapists in the mental health field.
For the convenience of the reader I begin by restating in summary form some of the features most distinctive of attachment theory.
? 244/362
? ? ? SOME DISTINCTIVE FEATURES OF ATTACHMENT THEORY
It will be remembered that attachment theory was formulated to explain certain patterns of be- haviour, characteristic not only of infants and young children but also adolescents and adults, that were formerly conceptualized in terms of de- pendency and over-dependency. In its original formulation observations of how young children respond when placed in a strange place with strange people, and the effects such experiences have on a child's subsequent relations with his parents, were especially influential. In all sub- sequent work theory has continued to be tied closely to detailed observations and interview data of how individuals respond in particular situations. Historically the theory was developed out of the object-relations tradition in psychoana- lysis; but it has drawn also on concepts from evolution theory, ethology, control theory, and cognitive psychology. One result is the reformula- tion of psychoanalytic metapsychology in ways compatible with modern biology and psychology and in conformity with the commonly accepted criteria of natural science (see Lecture 4).
Attachment theory emphasizes:
245/362
? ? ? (a) the primary status and biological function of intimate emotional bonds between individuals, the making and maintaining of which are postulated to be controlled by a cybernetic system situated within the central nervous system, utilizing working models of self and attachment figure in relation- ship with each other. 1
(b) the powerful influence on a child's development of the ways he is treated by his parents, especially his mother-figure, and
(c) that present knowledge of infant and child development requires that a theory of developmental pathways should replace theories that invoke specific phases of development in which it is held a person may become fixated and/or to which he may regress.
THE PRIMACY OF INTIMATE EMOTIONAL BONDS
Attachment theory regards the propensity to make intimate emotional bonds to particular in- dividuals as a basic component of human nature, already present in germinal form in the neonate and continuing through adult life into old age. During infancy and childhood bonds are with parents (or parent substitutes) who are looked to for protection, comfort, and support. During healthy adolescence and adult life these bonds persist, but are complemented by new bonds, commonly of a heterosexual nature. Although food and sex sometimes play important roles in attachment relationships, the relationship exists in its own right and has a key survival function of its own, namely protection. Initially the only means of communication between infant and
246/362
? ? ? mother is through emotional expression and its accompanying behaviour. Although supplemen- ted later by speech, emotionally mediated com- munication nonetheless persists as a principal feature of intimate relationships throughout life.
Within the attachment framework therefore in- timate emotional bonds are seen as neither sub- ordinate to nor derivative from food and sex. Nor is the urgent desire for comfort and support in adversity regarded as childish, as dependency theory implies. Instead the capacity to make in- timate emotional bonds with other individuals, sometimes in the careseeking role and sometimes in the caregiving one, is regarded as a principal feature of effective personality functioning and mental health.
As a rule careseeking is shown by a weaker and less experienced individual towards someone re- garded as stronger and/or wiser. A child, or older person in the careseeking role, keeps within range of the caregiver, the degree of closeness or of ready accessibility depending on circum- stances: hence the concept of attachment behaviour.
Caregiving, the major role of parents and com- plementary to attachment behaviour, is regarded
247/362
? ? ? in the same light as careseeking, namely as a ba- sic component of human nature (see Lecture 1).
Exploring the environment, including play and varied activities with peers, is seen as a third ba- sic component and one antithetic to attachment behaviour. When an individual (of any age) is feeling secure he is likely to explore away from his attachment figure. When alarmed, anxious, tired, or unwell he feels an urge towards proxim- ity. Thus we see the typical pattern of interaction between child and parent known as exploration from a secure base, first described by Ainsworth (1967). Provided the parent is known to be ac- cessible and will be responsive when called upon, a healthy child feels secure enough to explore. At first these explorations are limited both in time and space. Around the middle of the third year, however, a secure child begins to become confid- ent enough to increase time and distance away--first to half-days and later to whole days. As he grows into adolescence, his excursions are extended to weeks or months, but a secure home base remains indispensable nonetheless for op- timal functioning and mental health. Note that the concept of secure base is a central feature of the theory of psychotherapy proposed.
248/362
? ? ? During the early months of life an infant shows many of the component responses of what will later become attachment behaviour, but the or- ganized pattern does not develop until the second half of the first year. From birth onwards he shows a germinal capacity to engage in social in- teraction and pleasure in doing so (Stern, 1985): thus there is no autistic or narcissistic phase. Within days, moreover, he is able to distinguish between his mother-figure and others by means of her smell and by hearing her voice, and also by the way she holds him. Visual discrimination is not reliable until the second quarter. Initially cry- ing is the only means available to him for sig- nalling his need for care, and contentment the only means for signalling that he has been satis- fied. During the second month, however, his so- cial smile acts strongly to encourage his mother in her ministrations and his repertoire of emo- tional communications rapidly extends (Izard, 1982; Emde, 1983).
The development of attachment behaviour as an organized system, having as its goal the keep- ing of proximity or of accessibility to a discriminated mother-figure, requires that the child should have developed the cognitive
249/362
? ? ? capacity to keep his mother in mind when she is not present: this capacity develops during the second six months of life. Thus from nine months onwards the great majority of infants respond to being left with a strange person by protest and crying, and also by more or less prolonged fret- ting and rejection of the stranger. These observa- tions demonstrate that during these months an infant is becoming capable of representation and that his working model of his mother is becoming available to him for purposes of comparison dur- ing her absence and for recognition after her re- turn. Complementary to his model of his mother, he develops a working model of himself in inter- action with her, likewise for father.
A major feature of attachment theory is the hy- pothesis that attachment behaviour is organized by means of a control system within the central nervous system, analogous to the physiological control systems that maintain physiological measures such as blood pressure and body tem- perature within set limits. Thus the theory pro- poses that, in a way analogous to physiological homeostasis, the attachment control system maintains a person's relation to his attachment figure between certain limits of distance and
250/362
? ? ? accessibility, using increasingly sophisticated methods of communication for doing so. As such, the effects of its operation can be regarded as an example of what can usefully be termed environ- mental homeostasis (Bowlby, 1969, 1982). By postulating a control system of this sort (with analogous systems controlling other forms of be- haviour) attachment theory contains within itself a theory of motivation that can replace traditional theories which invoke a postulated build-up of energy or drive. Among several advantages of control theory are that it gives as much attention to the conditions terminating a behavioural se- quence as to those initiating it and is proving a fruitful framework for empirical research.
The presence of an attachment control system and its linkage to the working models of self and attachment figure(s) that are built in the mind during childhood are held to be central features of personality functioning throughout life.
PATTERNS OF ATTACHMENT AND CONDITIONS DETERMINING THEIR DEVELOPMENT
The second area to which attachment theory pays special attention is the role of a child's parents in determining how he develops. There is today
251/362
? ? ? impressive and mounting evidence that the pat- tern of attachment that an individual develops during the years of immaturity--infancy, child- hood, and adolescence--is profoundly influenced by the way his parents (or other parent figures) treat him. This evidence derives from a number of systematic research studies, the most impress- ive being prospective studies of socio-emotional development during the first five years under- taken by developmental psychologists who are also clinically sophisticated. Pioneered by Ainsworth (Ainsworth, Blehar, Waters, and Wall, 1978; Ainsworth, 1985) and expanded, notably by Main (Main, Kaplan, and Cassidy, 1985) and Sroufe (1983, 1985) in the United States and by Grossmann (Grossmann, Grossmann, and Sch- wan, 1986) in Germany, these studies are now multiplying fast. Their findings are remarkably consistent and have the clearest of clinical significance.
Three principal patterns of attachment, first described by Ainsworth and her colleagues in 1971, are now reliably identified, together with the family conditions that promote them. These are first the pattern of secure attachment in which the individual is confident that his parent
252/362
? ? ? (or parent figure) will be available, responsive, and helpful should he encounter adverse or frightening situations. With this assurance, he feels bold in his explorations of the world. This pattern is promoted by a parent, in the early years especially by mother, being readily avail- able, sensitive to her child's signals, and lovingly responsive when he seeks protection and/or comfort.
A second pattern is that of anxious resistant at- tachment in which the individual is uncertain whether his parent will be available or responsive or helpful when called upon. Because of this un- certainty he is always prone to separation anxi- ety, tends to be clinging, and is anxious about ex- ploring the world. This pattern, in which conflict is evident, is promoted by a parent being avail- able and helpful on some occasions but not on others, and by separations and, as clinical find- ings show, by threats of abandonment used as a means of control.
A third pattern is that of anxious avoidant at- tachment in which the individual has no confid- ence that, when he seeks care, he will be respon- ded to helpfully but, on the contrary, expects to be rebuffed. When in marked degree such an
253/362
? ? ? individual attempts to live his life without the love and support of others, he tries to become emotionally self-sufficient and may later be dia- gnosed as narcissistic or as having a false self of the type described by Winnicott (1960). This pat- tern, in which conflict is more hidden, is the res- ult of the individual's mother constantly rebuff- ing him when he approaches her for comfort or protection. The most extreme cases result from repeated rejections.
Although in most cases the pattern observed conforms fairly closely to one or another of the three well-recognized types, there have been puzzling exceptions. During the assessment pro- cedure used in these studies (the Ainsworth Strange Situation), in which infant and mother are observed in interaction during a series of brief episodes, certain infants have appeared to be disoriented and/or disorganized. One infant appears dazed; another freezes immobile; a third engages in some stereotypy; a fourth starts a movement, then stops unaccountably. After much study Main and her colleagues have con- cluded that these peculiar forms of behaviour oc- cur in infants who are exhibiting a disorganized version of one of the three typical patterns, more
254/362
? ? ? often than not the anxious resistant one (Main and Weston, 1981; Main and Solomon, 1990). Some instances are seen in infants known to have been physically abused and/or grossly neglected by the parent (Crittenden, 1985). Others occur in dyads in which the mother is suffering from a severe form of bipolar affective illness and who treats her child in an erratic and unpredictable way (Radke-Yarrow et al. , 1985). Yet others are shown by the infants of mothers who are still pre- occupied with mourning a parental figure lost during the mother's childhood and by those of mothers who themselves suffered physical or sexual abuse as children (Main and Hesse, 1990). Cases showing these deviant patterns are clearly of great clinical concern, and much attention is now being given to them.
Knowledge of the origins of these deviant pat- terns confirms in the clearest possible way the in- fluence on a child's pattern of attachment of the parent's way of treating his or her child. Yet fur- ther confirmatory evidence comes from detailed observations of the way different mothers treat their children during a laboratory session ar- ranged when the child is 21/2 years old (Matas, Arend, and Sroufe, 1978). In this study the child
255/362
? ? ? is given a small but difficult task for the solution of which he requires a little assistance, and his mother is free to interact with him. In this situ- ation, it is found, the way she treats him correl- ates closely with the pattern of attachment her child showed towards her 18 months earlier. Thus the mother of a child earlier assessed as se- curely attached is found to be attentive and sens- itive to his performance and to respond to his successes and difficulties in a way that is helpful and encouraging. Conversely the mother of a child earlier assessed as insecure is found to be less attentive and/or less sensitive. In some cases her responses are ill-timed and unhelpful; in oth- ers she may take little notice of what he is doing or how he is feeling; in yet others she may act- ively discourage or reject his bids for help and en- couragement. Note that the pattern of interaction adopted by the mother of a secure infant provides an excellent model for the pattern of therapeutic intervention advocated here.
In thus underlining the very great influence that a child's mother has on his development, it is necessary also to consider what has led a mother to adopt the style of mothering she does. One ma- jor influence on this is the amount of emotional
256/362
? ? ? support, or lack of it, she herself is receiving at the time. Another is the form of mothering that she herself received when a child. Once these factors are recognized, as they have been by many analytically oriented clinicians long since, the idea of blaming parents evaporates and is re- placed by a therapeutic approach. Since the emo- tional problems of parents stemming from the past and their effects on children has now be- come a field for systematic research, a brief de- scription of current work is given at the end of Lecture 8.
PERSISTENCE OF PATTERNS
If we return now to the patterns of attachment observed in one-year-olds, prospective studies show that each pattern of attachment, once de- veloped, tends to persist. One reason for this is that the way a parent treats a child, whether for better or for worse, tends to continue unchanged. Another is that each pattern tends to be self-per- petuating. Thus a secure child is a happier and more rewarding child to care for and also is less demanding than an anxious one. An anxious am- bivalent child is apt to be whiny and clinging; whilst an anxious avoidant child keeps his
257/362
? ? ? distance and is prone to bully other children. In both of these last cases the child's behaviour is likely to elicit an unfavourable response from the parent so that vicious circles develop.
Although for these reasons patterns, once formed, are apt to persist, this is by no means ne- cessarily so. Evidence shows that during the first two or three years the pattern of attachment is a property of the relationship, for example, child to mother or child to father, and that if the parent treats the child differently the pattern will change accordingly. These changes are amongst much evidence reviewed by Sroufe (1985) that stability of pattern, when it occurs, cannot be attributed to the child's inborn temperament as has sometimes been claimed. Nevertheless, as a child grows older, the pattern becomes increasingly a prop- erty of the child himself, which means that he tends to impose it, or some derivative of it, upon new relationships such as with a teacher, a foster- mother, or a therapist.
The results of this process of internalization are evident in a prospective study which shows that the pattern of attachment characteristic of a mother-child pair, as assessed when the child is aged 12 months, is highly predictive of how that
258/362
? ? ? 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.
