The inevitability of loss means that for Bowlby grief sometimes
outshines
attachment in importance, that his criticisms of psychoanalysis sometimes outweigh his praise, just as for the republican Milton, Satan and the underworld were more vibrant and interesting than the kingdom of God.
Bowlby - Attachment
Bowlby saw two main factors as being of etiological significance.
First, the separation itself:
Thus the essential factor which all these separations have in common is that, during the early development of his object- relationships, the child is suddenly removed and placed with strangers. He is snatched away from the people and places which are familiar and whom he loves and placed with people and in surroundings which are unknown and alarming.
(Bowlby 1944)
This must have struck many a sympathetic chord in readers who had survived six years of wartime evacuation, enforced separation and bereavement.
The second factor connecting delinquency and the 'affectionless character' with separation was the 'inhibition of love by rage and the phantasies resulting from rage'. The separated child responds to the absence of his parent with feelings of fury and destructiveness. Normally, as Klein and later Bion described, the soothing presence of the parent would enable these phantasies to be modified by reality, and therefore to give up their dominance in the child's mind. But if the mother is absent, or is herself aggressive and liable to retaliate rather than accept her child's anger, the growing child may be left harbouring phantasies of revenge and hatred which then become manifest in delinquent behaviour. This may be accompanied by an indifference born of
[the] determination at all costs not to risk again the disappointment and resulting rages and longings which wanting someone very much and not getting them involves . . . a policy of self-protection against the slings and arrows of their own turbulent feelings.
(Bowlby 1944)
We see in this early work the prefigurings of three of Bowlby's most insistent themes: the centrality of loss as a determinant of disturbance, the importance of the mother in neutralising and defusing the destructive effects of rage in response to loss, and the use of affective withdrawal as a defense against the pain of unmet longing or anger faced alone. Bowlby had already identified
88 Attachment Theory
the importance of expression of anger, rather than its repression, and the role of the parents in fostering or holding this back, in his pre-war study of aggression:
Take the child away from the fire, deny it a second piece of cake, but avoid being angry or hurt or disapproving if a scream of rage or a kick on the shins is the immediate consequence of thwarting a child's will to happiness. To permit children to express their feelings of aggression, whilst preventing acts of irremediable destruction is, we suggest, one of the greatest gifts that parents can give to their children.
(Durbin and Bowlby 1938)
As we saw in Chapter 3, Bowlby's own retrospective findings were buttressed by his review of the world literature on the effects of separation, and here too he emphasises the importance of active protest as a mark of a positive response to separation: 'a violent reaction is normal and an apathetic resignation a sign of unhealthy development' (Bowlby 1965).
PROSPECTIVE STUDIES: CHILDREN IN HOSPITAL
Together with James Robertson (Robertson and Bowlby 1952b), Bowlby was next able to establish by direct observation the effects on children of temporary separation from their parents. They studied the reactions of children who were taken into hospital, which in those days required almost complete absence of contact with parents during the admission (for fear of cross-infection), and a series of constantly changing carers in the hospital ward. Profound effects were noted,especiallyintheyoungeragegroups. Thechildreninitiallybecametearful, crying and calling bitterly for their parents, and rejecting the staff's attempts to mollify or distract them. Later, bored indifference and apathy seemed to take over, with the children isolating themselves from their peers, sitting listlessly staringintospace,playingandeatinglittle. Finally,childrenappearedto'recover' and to become active once more, but if hospitalisation was prolonged their relationshipswithadultsandotherchildrenappearedsuperficialandself-centered compared with before.
These three phases were described by Bowlby as the stages of protest, withdrawal and detachment. Feelings of protest reemerged when these separated children were reunited with their parents, who were subjected to a mixture of rejection (even to the point of failing to recognise them), angry attacks and clinging in the days following return from hospital.
Loss, anger and grief 89
Some of these changes were long-lived and could be detected up to two years later. They also found that the effects of separation could be mitigated by a number of common-sense measures including regular hospital visiting by parents, preliminary reconnaissance visits to the hospital ward, allowing children to take familiar comforting objects like teddy-bears with them when they went into hospital, and in the case of separations not involving hospital, placing them with adults who were previously known and trusted. All of these moves have by now become part of routine parental and pediatric practice.
AN ANATOMY OF MOURNING
The 1960s saw two important developments in the understanding of the psychological impact of loss. First, Bowlby was joined at the Tavistock by Colin Murray Parkes who undertook a systematic study of bereavement in adults which complemented and confirmed Robertson's (1952) earlier work with children (Parkes 1975). Second, the crystallisation of Attachment Theory provided a theoretical basis on which to understand these empirical findings.
Bowlby's theory of bereavement is essentially an extension of his theory of separation anxiety which we have considered in the previous chapter. He sees anxiety as realistic response to separation or threatened separation of a vulnerable individual from his care- giver. Since care-seeker and care-giver form a reciprocal partnership, and since the attachment dynamic continues throughout adult life, separation anxiety will arise whenever the parent-child, adult-spouse or adult-companion relationship is threatened. The components of separation anxiety include a subjective feeling of worry, pain and tension; angry protest, whose function is to register displeasure and to punish the errant partner so as to prevent repetition; and a restless searching for the missing person.
Bowlby sees the grief reaction as a special case of separation anxiety, bereavement being an irreversible form of separation. He believes that the psychological response to the trauma of separation is biologically programmed in the same way that the inflammatory response is an orderly sequence of physiological responses to physical trauma - redness, swelling, heat and pain. The early phases of grief consist of an intense form of separation anxiety. The later phases result from the confusion and misery that arise from the realisation that the secure base to whom the
90 Attachment Theory
bereaved individual would turn for comfort in distress is the very person who is no longer available. With this in mind, let us look now at the four phases of mourning (Bowlby 1980, 1982a, 1988a) in more detail.
Stage 1: numbing
A soldier wounded on the field of battle may feel no pain and continue to fight until help is at hand. In the same way, perhaps, the very earliest response to a sudden bereavement may be an apparent calmness based on emotional shutdown in which all feelings are suppressed, or reality denied, until the bereaved person is in a safe enough situation to let go a little.
A bereaved wife in the casualty department
A young scaffolder was brought into the casualty department dead, having fallen from a tall building. There were no external signs of injury. When his wife arrived she was completely and chillingly calm, expressing no emotion, simply saying: 'Oh, but he's not dead, he's asleep, doesn't he look beautiful and peaceful. ' It was only when, several hours later, her mother arrived that she began to sob and wail uncontrollably.
Stage 2: yearning, searching, anger
Bowlby places the search for the lost object at the centre of the mourning response. There may be physical restlessness and wandering as the bereaved person goes from room to room, from place to place, scanning, looking, hoping that their lost loved one may reappear. A similar process goes on psychologically in which the bereaved person goes over in their mind every detail of the events leading up to the loss, in a kind of compulsive 'action replay', hoping that some mistake may have been made and that past events can be made to turn out differently.
Freud (1917) saw the purpose of this mental searching as that of detachment: 'Mourning has a quite precise psychical task to perform: its function is to detach the survivor's memories and hopes from the dead. ' Bowlby, by contrast, sees purpose in evolutionary rather than teleological terms, and views the mental
Loss, anger and grief 91
searching of the bereaved as an attempt to recover and be reunited with the lost object. Similarly, Bowlby's understanding of the prevalence of visual images of the dead person that so often haunt the bereaved is of an intense 'perceptual set' towards the sight and sound of the lost person that can lead to misinterpretation of auditory and visual clues. Just as the 3-month-old infant quickens at the sound of his mother's footsteps and scans his visual field anxiously until he can meet her greeting smile with his, so the bereaved person is desperately trying to track down his missing attachment figure. Following Darwin (1872), Bowlby sees the facial expressions and crying of the bereaved as a resultant of the tendency to scream in the hope of awakening the attention of a negligent care-giver, and the social inhibition of such screaming.
Anger too is part of the normal response to separation: 'almost every separation has a happy ending, and often a small or large dash of aggression will assist this outcome' (Bowlby 1961c). Bowlby emphasises again and again the importance of the expression of anger if the bereaved person is to recover:
Only if he can tolerate the pining, the more or less conscious searching, the seemingly endless examination of why and how the loss occurred, and anger at everyone who might be responsible, not even sparing the dead person, can he gradually come to realise and accept that loss is in truth permanent and that his life must be shaped anew.
(Bowlby 1982a)
The anger so often seen towards potential comforters whose aim is to help the bereaved person 'come to terms' with the loss, or towards doctors responsible for the care of the dead person, can be understood in this light too. They represent the loss of hope that the loved one might somehow be alive. Their cold comfort can trigger an angry outburst in one who, already weakened by the stress of loss, wants nothing less than to be reminded that the loss is indeed irrecoverable. If only someone can be blamed then this allows the 'secret hope
92 Attachment Theory
that perhaps in some miraculous way to seek out the villain will lead to recovery of loss' (Bowlby 1961c).
The lonely widow
Marion was fifty-five when her husband died suddenly of a heart attack. Childless, they had been married for thirty years and had returned to the United Kingdom after years of living overseas, having lost all their possessions in a fire. Marion had relied on her husband for everything, sheltering behind his competence and social confidence. She 'coped' well at first after his death, but then was admitted to hospital after taking a large overdose. She had only been found in time because the milkman had noticed uncollected bottles and raised the alarm. When she recovered she explained how furious she had felt when her doctor (who had failed in her eyes to save her husband's life) had summoned her for a cervical smear test, without apparently realising that she had had a hysterectomy some years previously.
Therapy with her meant withstanding a torrent of fury about the unfairness of life. She blamed the doctors, the laxity of modern society (the England she had returned to was such a different place from the one she had left), the insurance companies, the Government - everyone. She agreed reluctantly to try not to kill herself, although she continued to insist that life without her husband was futile and meaningless. Contrary to expectation, exploring her childlessness, of which the GP's summons had reminded her, did not lead to feelings of sadness about her lack of children. Instead she revealed how she, unlike her husband, had never wanted children since she feared that this would divert his care and attention from her, as she felt had happened with her mother in her family (she, like Bowlby's mother, was the oldest of six) when her younger siblings were born. A history of excessive dependency and exclusive monotropism is a significant predisposing factor towards prolonged grief reactions (Parkes 1975).
Stages 3 and 4: disorganisation and despair: reorganisation
The diagram of the attachment relationship (Figure 4. 1) shown in the previous chapter depicted a dynamic equilibrium between
Loss, anger and grief 93
care-seeker and care-giver, constantly monitored, quiescent at times of exploration, activated at times of stress. Bowlby (1980) likens the shock of loss to a see-saw in which one person is suddenly removed, and quotes C. S. Lewis on his widowerhood: 'So many roads once; now so many culs-de-sac. ' The basic dilemma of the bereaved is, as we have said, that the loss removes not only the loved one, but also the secure base to which the bereaved person would expect to turn in their hour of need.
Loss throws the inner world of the sufferer into turmoil. All the assumptions and expectations which depended on the presence of the loved one are now thrown into question. Where can the bereaved person find hope and comfort in the face of his inner turmoil and confusion? The quasi-depressive state which marks the third stage of grief can be understood in a number of ways. Freud (1917) recognised that some internal work was occurring which was necessary before the person could begin to form new attachments. For him the key feature was identification with the lost object; in Klein's (1986) word, the lost person is 'reinstated' in the inner world in the course of healthy grief so that he or she forms part of a composite internal representation of reality.
Melanie Klein (1986) sees the depression and apathy and withdrawal of the bereaved as a regression to infancy, a result of the assault on the security of the inner world which has been so painstakingly built up through childhood. For Klein grief is 'shot through with persecutory anxiety and guilt' (Bowlby 1961a) because the bereaved person is thrown back to the abandonments and failures of early childhood. During the phase of disorganisation the bereaved person is constantly questioning and questing, but 'reality passes its verdict - that the object no longer exists - upon each single one of the memories and hopes' (Klein 1986). Just as the infant, through maternal tolerance and capacity to process conflict and negative affect learns that the lost breast will reappear, that his anger has not destroyed his mother's love, so the bereaved person begins once more to build up his inner world:
every advance in the process of mourning results in a deepening in the individual's relation to his inner objects, in the happiness of regaining them after they were felt to be lost. This is similar
94
Attachment Theory
to the way in which the young child step by step builds up his relation to external objects, for he gains trust not only from pleasant experiences, but also from the ways in which he overcomes frustrations and unpleasant experiences, nevertheless retaining his good objects.
(Klein 1986)
Bowlby is critical of Klein for what he sees as her overemphasis on the persecutory aspect of normal (as opposed to abnormal) grief, and for her neglect of the reality of the danger to which the bereaved person is exposed (widowers die of a broken heart more frequently than comparable non-bereaved men). Nevertheless, her account of the impact of death on the internal world is entirely compatible with the Bowlbian view that the work of grief consists of rebuilding a secure inner base, that the building of secure attachment depends on a secure holding environment which in the past has been reliable enough to withstand and process hostility, and that new attachments can only be formed once old ones are relinquished.
A widower - at twenty-six
Jock was a tough shipbuilder from the Clyde. At twenty-six his wife died suddenly of a cerebral haemorrhage, leaving him with six children aged eight to 6 months. He tried for a few weeks to carry on as normal but suddenly took all the children to his sister and brother-in-law and set off for London. There he led the life of a tramp, living on the streets and in doss houses, drinking heavily, fighting a lot and moving on. Eventually he was brought to the emergency clinic of the hospital, where he told his story. He spoke of his feelings of rage and fury towards his wife for abandoning him, about which he felt intensely guilty and about his incomprehension that God (he was a devout Catholic) should have allowed such a thing to happen to him; of the despair and chaos which he felt inside; of his wish to smash anyone and everyone who thwarted or tried to control him; and of his need to drink to blot out the pain of losing the wife whom he loved so much. His drinking and way of life continued, but he went on coming to the clinic to talk. Then, suddenly and without warning he disappeared. A few weeks later he wrote saying that he had returned to Glasgow, had stopped drinking and was now happily looking after the children. A further letter about a year later confirmed that things continued to go well.
Loss, anger and grief 95
Perhaps Jock felt sufficiently 'held' (in the Winnicottian sense) by his weekly contact with the therapist at the hospital to be able to rebuild his inner world so that he could become once more a secure base for his children - leaving his therapist as abruptly as his wife had 'left' him. For Bowlby the opportunity for emotional release is an essential ingredient in healthy mourning, avoiding the defensive manoeuvres which unexpressed emotion requires:
The behaviour of potential comforters plays a large part in determining whether a bereaved person is sad, perhaps dreadfully sad, or becomes despairing and depressed as well . . . if all goes well, since he will not be afraid of intense and unmet desires for love from the person lost, he will let himself be swept by pangs of grief and tearful expressions of yearning, and distress will come naturally.
(Bowlby 1982a)
MOURNING AND ADULT PSYCHOPATHOLOGY
Bowlby's early studies had convinced him of the far-reaching effects of separation and bereavement in childhood. He was convinced that much of adult psychiatric disability could be traced back to such traumata. This view is supported by recent psychophysiological findings that early separation can have long- lasting effects on the sensitivity of brain receptors, leading to permanently raised anxiety levels (Van de Kolk 1987; Gabbard 1992). Post (1992) has similarly argued that depression in adult life may originate with environmental trauma that is encoded in brain changes in protein and RNA, on the analogy of the 'kindling' phenomenon in epilepsy in which the sensitivity of brain cells becomes progressively greater with each seizure, so that what starts as a response to an environmental stimulus becomes eventually an intrinsic feature of the brain.
Bowlby was also convinced that the response of the adult world to a child's distress had a decisive influence on the outcome of loss. He was implacably opposed to the stiff- upper-lip attitude, and disparagement of 'childishness' which epitomised his generation, class and profession. Love, tenderness, encouragement of emotional expression even if hostile, and acceptance of the lifelong imperative for mutual dependency were his watchwords.
96 Attachment Theory
Recent epidemiological research (Tennant 1988) suggests that the influence of childhood bereavement per se on adult psychiatric disorder is probably less significant than Bowlby imagined. Parental disruption and disturbance is a much more potent cause of difficulty and depression than loss in itself. But, as we shall see in Chapters 6 and 9, the current evidence suggests that Bowlby was right to emphasise the real nature of environmental influence and to make quite sharp distinctions between normal and abnormal developmental patterns, a point which he felt the psychoanalysts consistently fudged. His hunch that loss was a key research issue has been proved right, but in a more subtle way than he might have imagined, and one which is compatible with the Kleinian view from which he was so careful to distance himself. The manner in which a child's carers respond to her or his reactions to loss, whether major or minor - to the anger and pining and demandingness - may crucially influence that child's subsequent development. The establishment of a secure internal base, a sense that conflict can be negotiated and resolved, the avoidance of the necessity for primitive defences - all this depends on parental handling of the interplay between attachment and loss that is the leitmotiv of the Bowlbian message.
COMPANIONSHIP AND ATTACHMENT: A POETIC POSTSCRIPT
Being highly intelligent, very well-organised and slightly obsessional, Bowlby was a master of any topic to which he put his mind: for example, he re-read the whole of Freud during his Stanford fellowship in 1957. The corollary of this was that he tended to avoid those few subjects of which he had only passing or partial knowledge, one of which was English literature (U. Bowlby 1991). Having no such scruples - perhaps to my discredit - I conclude this chapter by considering three classic poems of grief from the English canon, which in their non-scientific way lend some support to Bowlby's thesis on mourning.
Milton's Lycidas and Tennyson's In Memoriam are both poems by young men about the loss of loved and valued fraternal comrades. It is debatable whether friendship (and sibship) fulfil the criteria of proximity seeking, secure-base effect and separation protest which are the hallmarks of a full-blown attachment relationship. Weiss (1982) distinguishes the companionship provided by friends from the intimacy of adult attachment typically to be found in a sexual
Loss, anger and grief 97
partnership. He showed how wives who move because of their husband's job to new towns felt cut off from their friends and bored, but did not experience the specific empty loneliness that widows or separated people feel when loss of a spouse first hits. Similarly, Heard and Lake (1986) write about the need for 'like- minded companions of similar experience and stamina with whom to engage in mutually interesting and enjoyable activities' as part of the 'attachment dynamic'. A cursory glance at any lonely hearts column will attest to the reality of this need. The prime role of friendship seems to facilitate exploratory activity rather than to provide a secure base, although without a secure base no exploration is possible, and many intimate relationships, especially marriage, provide both. It seems likely that friendship or sibship does have a more central role as a source for a secure base in certain circumstances: in adolescence; among comrades in intense and isolated circumstances such as the armed services or mountaineering expeditions; and between siblings when the parental relationship is difficult or defective. The latter was certainly the case for Tennyson, who had an extremely unhappy and tormented childhood which he survived mainly through his writing and intelligence (Hamilton 1986), and, from his teenage years, through his friendship with Arthur Hallam who, although two years younger, became his mentor, sponsor and champion. Hallam's premature death when Tennyson was only twenty-four led to near- breakdown for the poet. In Memoriam was started within weeks of the loss, but was only completed and published some thirteen years later.
Milton's Lycidas 'bewails' the death of a 'learned friend' (Edward King) drowned in the Irish Sea - like Tennyson's Hallam, a childhood companion and one who shared Milton's radical anti-clericalism. Milton's mother had died a few months earlier; numbed, Milton had apparently been unable to write anything to mark her loss. The scene is pastoral and the two friends are depicted as shepherds. The need at times of grief to return to the good object (breast-hill) is evoked:
98 Attachment Theory
For we were nursed upon the self-same hill, Fed the same flock by fountain, shade, and rill.
The centrepiece of the poem is the attack on the 'corrupted clergy then in their height', drawn as self-serving, ignorant shepherds. Like so many prematurely bereaved people, Milton rails against the injustice of fate: why has my loved one died, who did not deserve it, and not those undeserving souls who live on?
'How well could I have spared for thee, young swain, Enow of such as for their bellies' sake
Creep, and intrude, and climb into the fold! . . .
Blind mouths! that scarce themselves know how to hold A sheep-hook . . .
The hungry sheep look up, and are not fed,
But swoln with wind, and the rank mist they draw, Rot inwardly, and foul contagion spread. '
The inner world is contaminated and fouled by the anger and despair of the poet, then projected onto the corrupt priests who are held to blame for the loss.
The action of the poem takes place in a single night in which the poet passes through the stages of sadness, despair, anger, blame and depression until he reaches acceptance, with the help of two images from the natural world. The first are the garlands of flowers with which to 'strew the laureat hearse where Lycid lies', and which serve to link the loss of Lycidas with the natural transience of beauty. In the second he pictures the sun setting over the ocean where Lycidas is drowned, only to rise again the next morning,
and with new spangled ore
Flames in the forehead of the morning sky.
An image of setting and rising, of separation and reunion, has replaced the sense of irretrievable loss. A secure base is reestablished, mirroring perhaps the regular appearance and disappearance of the feeding mother. The poet can begin once more to explore, no longer enshrouded, but enveloped by a cloak that moves and lives:
At last he rose, and twitched his mantle blue: To-morrow to fresh woods and pastures new.
In In Memoriam we see many of the same themes. In recalling his love for Hallam, Tennyson is taken back to pre-verbal
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paradisial times before the loss, reminiscent of the mother's attunement to her baby's needs, which leads, in Winnicottian terms, to the opening out of a transitional space between them. The poet describes the two friends' sense of intuitive, empathic understanding:
Dear as the mother to the son More than my brothers are to me . . .
Thought leapt out to wed with Thought Ere thought could wed itself with speech.
But then the dreadful boat brings the dead body home. Tennyson contrasts his own empty hands and those reunited with their attachment figures:
Thou bring'st the sailor to his wife
And travelled men from foreign lands And letters unto trembling hands
And, thy dark freight, a vanished life.
Tennyson tackles the tragic implications of monotropism: attachments are not transferable, or only so by a slow and painful process of withdrawal and re-attachment. By contrast, nature becomes an indifferent mother who cares equally and indiscriminately for all her 'children' and has no special affection for any one of them.
Are God and Nature then at strife,
That Nature lends such evil dreams? So careful of the type she seems,
So careless of the single life?
Despair strikes, meaning is destroyed, when the interplay of attachment, with its mutual reinforcement, its linking of inner world and outer reality is disrupted:
'So careful of the type'? But no.
From scarped cliff and quarried stone She cries, 'A thousand types are gone;
I care for nothing, all shall go. '
Loss throws us back to our childhood, to our primary attachments:
100 Attachment Theory
but what am I?
An infant crying in the night: An infant crying for the light:
And with no language but a cry.
Tennyson begins to think on a new time-scale and to see the possibility of new attachments, as one generation succeeds another:
Unwatch'd, the garden bough shall sway, The tender blossom flutter down . . .
Till from the garden and the wild
A fresh association blow,
And year by year the landscape grow
Familiar to the stranger's child.
Finally he returns to the image of mother and child, to the hatching of individuality from their symbiotic mixed-upness (Balint 1964). The mother's 'roundness' takes him round the corner of his developmental pathway towards a less despairing separation in which the inner world is strengthened and clarified:
The baby new to earth and sky
What time his tender palm is prest Against the circle of the breast
Has never thought that 'this is I'
So rounds he to a separate mind
From whence clear memory may begin As through the frame that binds him in
His isolation grows defined.
So it is with grief where, if all goes well, can come a strengthening of the inner world, of memory and definition. As we shall argue in Chapter 8, the importance of telling a story, of 'clear memory' is central to the poet's (and the psychotherapist's) mission.
John Donne's 'A Valediction: forbidding mourning' also concerns a sea voyage, and also uses the image of a 'round' or circle as an antidote to the abyss of loss and separation. This is a poem about anticipatory grief, given by Donne to his wife before setting sail for France in November 1611 (Gardner 1957).
He starts by advocating a slipping away on parting, which he compares with death, rather than an abrupt and emotional separation:
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As virtuous men pass mildly away,
And whisper to their soules to goe Whilst some of their sad friends doe say
The breath goes now, and some say no.
He contrasts their love which that of 'dull sublunary lovers', who lack a secure inner base and who therefore are dependent on one another's physical presence. They
cannot admit
Absence, because it doth remove
Those things which elemented it. But we . . .
Interassured of the mind,
Care lesse, eyes, lips, and hands to misse.
He pictures the invisible but precious bonds which link carer and cared-for, lover and beloved in an attachment relationship as slender threads of gold:
Our two souls therefore, which are one, Though I must goe, endure not yet A breach, but an expansion,
Like gold to ayery thinnesse beate.
Then, in another brilliant metaphysical metaphor, he imagines the internal working model of self and other as the two ends of a pair of compasses:
Thy soule the fixt foot, makes no show To move, but doth, if th'other doe.
And though it in the center sit,
Yet when the other far doth rome,
It leanes, and hearkens after it,
And growes erect, as it comes home. . .
Thy firmnes makes my circle just,
And makes me end, where I begunne.
We have mentioned how Bowlby says little about sexuality and is at pains to separate 'mating behaviour' from 'attachment behaviour'. The sexual imagery of this poem - despite appearances to the contrary ladies do move, perhaps 'grow erect' even, the
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lover 'ending' (that is, in orgasm) where he 'begun' (namely, was born) - combines in a profound way sexuality and attachment. The rhythm of sexuality, of coming together and separating, is linked both with death and the parting of soul from body at the start of the poem, and with birth at the end. They are held together by the central image of the secure base or 'inter-assurance' of lover and beloved. Seen in this way, attachment is a unifying principle that reaches from the biological depths of our being to its furthest spiritual reaches.
The inevitability of loss means that for Bowlby grief sometimes outshines attachment in importance, that his criticisms of psychoanalysis sometimes outweigh his praise, just as for the republican Milton, Satan and the underworld were more vibrant and interesting than the kingdom of God.
Chapter 6
Attachment Theory and personality development: the research evidence
It is just as necessary for analysts to study the way a child is really treated by his parents as it is to study the internal representations he has of them, indeed the principal form of our studies should be the interaction of the one with the other, of the internal with the external.
(Bowlby 1988a)
One of Bowlby's main reasons for re-casting psychoanalysis in the language of Attachment Theory was the hope that this would make it more accessible for empirical testing. This hope has been fully justified. The past thirty years have seen an explosion of research in infant and child development, a major part of which has arisen directly from the work of Bowlby and Mary Ainsworth in the 1950s and sixties. The aim of this chapter is to show how these findings point to aremarkablyconsistentstoryabouttheemergenceofpersonality,or'attachment style', out of the matrix of interactions between infant and care-givers in the early months and years of life. The issue of how what starts as interaction becomes internalised as personality is a key question for developmental psychology. Object-Relations Theory rests on the assumption that early relationships are a formative influence on character. I hope to demonstrate in this and the following chapter that Bowlby's movement away from psychoanalysis has come full circle and produced ideas that are highly relevant to,andprovidestrongsupportandenrichmentfor,thepsychoanalyticperspective.
As a scientific discipline, Attachment Theory has two great advantages over psychoanalysis. First, it rests on direct observation of parent-child interaction, rather than on retrospective
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reconstructions of what may or may not have gone in a person's past. Second, it starts from the observation of normal development, which can then be used as a yardstick against which to understand psychopathology, rather than building a theory of normal development from inferences made in the consulting room. It is perhaps no accident that the psychoanalyst with whom Bowlby has most in common, Winnicott, was also keenly aware of normal developmental processes through his earlier work as a pediatrician. Winnicott and Bowlby both believed that their observations of normal development were relevant to psychotherapy, for by getting a picture of what makes a good parent, we are likely to be in a better position to know what makes a good psychotherapist.
MARY AINSWORTH AND THE STRANGE SITUATION
There is an intimate relationship between technology and scientific advance. Galileo's observations depended on the expertise of the sixteenth-century Italian lens grinders; Darwin's discoveries sprang from the navigational and cartographic skills of Victorian maritime imperialism. Ainsworth's 'Strange Situation', 'a miniature drama in eight parts' (Bretherton 1991a) for mother, one-year-old infant and experimenter, has established itself as an indispensable tool in developmental psychology.
Ainsworth devised the Strange Situation in the late 1960s as part of her studies of mother-child interaction in the first year of life. She had worked with Bowlby in the 1950s, then moved to Uganda where she had made naturalistic studies of mothers with their babies, and finally settled in Baltimore, Maryland. Influenced by Attachment Theory, although at first wary of its ethological bias, she was interested in the relationship between attachment and exploratory behaviour in infants, and wanted to devise a standardised assessment procedure for human mothers and their children which would be both naturalistic and could be reliably rated, comparable to the methods used by animal experimenters like Harlow (1958) and Hinde (1982b).
The Strange Situation (Ainsworth et al. 1978) consists of a twenty-minute session in which mother and one-year-old child are first introduced into a playroom with an experimenter. The mother is then asked to leave the room for three minutes and to return, leaving the child with the experimenter. After her return
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and the re-union with the child, both mother and experimenter go out of the room for three minutes, leaving the child on its own. Mother and child are then once more re-united. The whole procedure is videotaped and rated, focusing particularly on the response of the child to separation and re-union. The aim is to elicit individual differences in coping with the stress of separation. Initially three, and later four, major patterns of response have been identified:
1. Secure attachment ('B') These infants are usually (but not invariably) distressed by the separation. On re-union they greet their parent, receive comfort if required, and then re- turn to excited or contented play.
2. Insecure-avoidant ('A') These children show few overt signs of distress on separation, and ignore their mother on re-union, especially on the second occasion when presumably the stress is greater. They remain watchful of her and inhibited in their play.
3. Insecure-ambivalent (insecure-resistant) ('C') They are highly distressed by separation and cannot easily be pacified on re- union. They seek contact, but then resist by kicking, turning away, squirming or batting away offered toys. They continue to alternate between anger and clinging to the mother, and their exploratory play is inhibited.
4. Insecure-disorganised ('D') This small group has recently been demarcated. They show a diverse range of confused behaviours including 'freezing', or stereotyped movements, when re-united with their parent.
In Ainsworth's original middle-class Baltimore sample the proportions were 'B' (secure) 66 per cent, 'A' (avoidant) 20 per cent, and 'C' (ambivalent) 12 per cent. 'D' had not been identified at that stage. Since her original publication, the Strange Situation has been used in well over thirty different studies (Ijzendoorn and Kroonenberg 1988), and is generally accepted as a reliable and valid instrument - comparable perhaps to the widespread use of the Expressed Emotion scales in psychiatry (Left and Vaughn 1983; see Chapter 9). There are significant cross-cultural variations, so that 'A' (avoidant) classifications tend to be commoner in Western Europe and the United States, while 'C' (ambivalent) is commoner in Israel and Japan. Intra-cultural
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variation between different socio-economic groups and between disturbed and non-disturbed families is greater than inter-cultural variance.
A whole set of research and theoretical questions follows from the establishment of this robust research tool. What is the meaning of the different patterns of response? Are they stable over time, and if so for how long? Do they predict disturbed behaviour later in childhood? Do they, as psychoanalytic theory might assume, persist into adult life? Can they be related to patterns of maternal- infant interaction in the early months of life? If maternal handling is relevant to classification pattern, what is the relationship between this and the mother's own experience of being mothered? If so, what are the psychological mechanisms by which attachment patterns are carried over from one generation to the next? Can patterns be altered by therapeutic intervention? The remainder of this chapter will be devoted to a discussion of these and related questions.
THE ROOTS OF SECURE AND INSECURE ATTACHMENT
Bowlby saw personality development primarily in terms of environmental influence: relationships rather than instinct or genetic endowment are primary. Differing patterns of attachment result from differing patterns of interaction, rather than being a reflection of infant temperament, or instinct. Sroufe (1979) makes an important distinction between 'emergent patterns of personality organisation' as revealed in the Strange Situation, and temperament, the latter representing quasi-physiological styles of behaviour, while the former reflect much more complex habitual relationship patterns. Thus babies may be sluggish, or active, 'cuddly' or non-cuddly, slow or fast, but still be classified as secure. Even more telling is the finding that children have different, but characteristic, attachment patterns with their two parents, and may be classified as secure with one and insecure with the other. This argues strongly that attachment patterns are a feature of the parent-child relationship, as yet not 'internalised' at one year, although by 18 months patterns have become more stable, with maternal patterns tending to dominate over paternal.
The Strange Situation research was part of a much larger study in which Ainsworth and her colleagues visited mothers and their
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infants regularly for periods of observation and rating during the whole of the first year of life. She found that attachment status at one year correlated strongly with the maternal relationship in the preceding twelve months, and this finding has been replicated in several other centres (Main and Weston 1982; Grossman et al. 1986; Sroufe 1979). In summary, prospective studies show that mothers of secure one-year-olds are responsive to their babies, mothers of insecure-avoidants are unresponsive, and mothers of insecure-ambivalents are inconsistently responsive.
The key to secure attachment is active, reciprocal interaction (Rutter 1981), and it seems that it is quality of interaction more than quantity that matters - a finding that contradicts Bowlby's earlier view on the causes of maternal deprivation. Passive contact alone does not necessarily promote attachment. Many babies are strongly attached to their fathers even though they spend relatively little time with them, and kibbutzim-reared children are more strongly attached to their mothers than to the nurses who feed them and look after them during the day, but often without much active interaction. In the first three months, mothers of secure infants respond more promptly when they cry; look, smile at and talk to their babies more; and offer them more affectionate and joyful holding. Mothers of avoidant children tend to interact less, and in a more functional way in the first three months, while mothers of ambivalents tend to ignore their babies' signals for attention and generally to be unpredictable in their responsiveness. By the second half of the first year, clear differences can be detected in the babies, and those who will be classified as secure at one year cry less than the insecure group, enjoy body contact more, and appear to demand it less (Bretherton 1991b).
The factor which mothers of insecurely attached children have in common can be understood in terms of Stern's (1985) concept of maternal attunement. He shows how sensitive mothers interacting with their children modulate their infant's rhythms so that when activity levels fall and the infant appears bored the mother will stimulate them, and when the child becomes overstimulated the mother will hold back a little so as to restore equilibrium. In cross-modal attunement the mother follows the baby's babbling, kicking, bouncing and so on with sounds or movements of her own that match and harmonise with those of the baby, although they may be in a different sensory mode. As he bounces up and down she may go 'Oooooh . . . Aaaaah . . . ',
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matching the tempo and amplitude of her responses to the baby's movements. This helps, as Stern sees it, in the development of the infant's sense of integrated selfhood. These processes of attunement are impaired in mothers of insecurely attached infants, leading to 'derailment' or mismatching in maternal response (Beebe and Lachmann 1988): thus mothers of ambivalently attached children can be observed to force themselves on their children when they are playing happily, and ignore them when they are in distress.
Brazelton and Cramer (1991) propose a similar model in which they break down the components of secure mother-child interactive patterns into four main features: synchrony (temporal attunement), symmetry (matching of actions), contingency (mutual cueing), and 'entrainment' (the capturing of each other's responses into a sequence of mutual activity). On the basis of this, play, and later infant autonomy, begins to emerge. Insecure attachments result from intrusiveness or under-responsiveness. They have developed an experimental model of the latter in their 'still face' experiments in which the infant is momentarily presented with an unmoving image of the mother, who is prohibited from picking up the baby or responding to it. The baby shows disappointment, gaze aversion and self-soothing strategies, which match those seen in the children of clinically depressed mothers.
As we have seen in the previous chapter, aggression is a major component of the initial response to threatened separation. Both patterns of insecure attachment can perhaps be understood in terms of the interplay between the need for attachment and the aggressive response to the threat of separation. The ambivalently attached child shows overt aggression towards the inconsistent mother who, in the Strange Situation, has just 'abandoned' him for two successive periods (albeit only for 3 minutes - but how was the one-year-old to know that? ). It is as if he is saying, 'Don't you dare do that again! ', but clinging on at the same time since he knows from experience that she will. The avoidant child shows little overt aggression in the Strange Situation, although these children do show outbursts of unprovoked aggression at home. It may be that the avoidant response is a way of dampening aggression and so appeasing the mother to whom the child needs desperately to feel close, but whom he fears will rebuff him if he reveals his needs too openly, or shows her how angry he feels about being abandoned (Main and Weston 1982).
Attachment Theory and personality development 109
The clock-watcher
A clinical example of avoidant attachment in adulthood is provided by a patient who, although faithfully reliable in her attendance at therapy, found it difficult to enter affectively into sessions which consisted mostly of a catalogue of the preceding week's events. She was meticulous about timekeeping, kept a close eye on her watch throughout the sessions, because, she said, she was terrified to overrun by a single second. As a solicitor she knew how annoying it was when clients outstayed their allotted time. The effect of this clock-watching was quite irritating to her therapist, who commented that timekeeping was his responsibility and tried to persuade her to remove her watch for sessions. It then emerged that her phantasy was that without her watch she would get 'lost' in the session, lose control of her feelings and at just that moment the therapist would announce that it was time to stop; she would then get so angry she would 'disgrace' herself, the therapist would not tolerate this and would break off the treatment. She had been a rather 'good' if distant child who had spent a lot of time on her own, while her older sister had been renowned for her tantrums and angry outbursts. By keeping her distance in a typically avoidantly-anxious pattern, she had maintained some sort of contact with her therapist (and presumably as a child, her parents), while avoiding the danger of threatening her tenuous attachments with her rage. She also kept some sort of coherence in the face of fear of disintegration. The price she paid for this adaptation was affective distancing, low self-esteem ('He would not tolerate me if he knew what I was really like') and the lack of a sense of movement and growth in her life.
THE STRANGE SITUATION AS A PREDICTOR OF SOCIAL ADJUSTMENT
The idea that anxious attachment patterns represent an adaptation or compromise to a sub-optimal environment is borne out by follow-up studies of children classified at one, and tested at pre- school, on school entry and again at ten (Bretherton 1985). At two years, securely attached children have a longer attention span, show more positive affect in free play, show more confidence in using tools, and are more likely to elicit their mother's help in
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difficult tasks compared with anxiously attached children. Their nursery teachers (blind to attachment status) rate them as more empathic and compliant and higher on positive affect. In peer interaction avoidants are hostile or distant, while ambivalents tend to be 'inept' and to show chronic low-level dependency on the teacher, and to be less able to engage in free play by themselves or with peers.
Evidence that the patterns of behaviour defined by the Strange Situation behaviour carry forward into subsequent development comes from the Grossmans (1991), who have shown that patterns of behaviour on re-union were 87 per cent predictable between one year and six years. They also showed that six-year-olds classified at one year as secure played concentratedly and for longer, were more socially skillful in handling conflict with their peers, and had more positive social perceptions, compared with children who had been rated as insecure as infants. Sroufe (1979) sees secure-rated children as having greater ego control and ego resiliency than those who were insecure. Secure children were rated by their teachers as neither overcontrolled nor undercontrolled, while avoidants were overcontrolled, ambivalents undercontrolled. Resiliency was inferred from such statements as 'curious and exploring', 'self-reliant, confident'. Stroufe concludes: 'What began as a competent caregiver-infant pair led to a flexible resourceful child. . . . Such predictability is not due to the inherently higher IQ of the securely attached infant, or, apparently, to inborn differences in temperament. '
LANGUAGE, NARRATIVE, COHERENCE
So far we have confined our account to attachment behaviour. As we look now at older children and their mothers, we turn to the trickier but psychotherapeutically more salient topics of the nature of attachment experience, its internal representation and how it manifests itself in language.
Main et al. (1985), Bretherton (1991b) and Cassidy (1988) have tried to tap into the child's experience of attachment by the use of play techniques such as a picture completion task, story completion, and puppet interview and story all depicting in different ways episodes of separation and re-union. Children tend to reveal their attachment histories through their play and imaginative activity. Avoidant children at six tend to draw figures
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with blank faces and no hands, suggesting a lack of responsiveness and holding in their lives. Secure children in response to a picture- story task give coherent, elaborated responses, including references to their own separation experiences, and are able to suggest positive ways in which separated figures could resolve their difficulties. Avoidant children, by contrast, describe separated children as sad, but cannot think of ways to help them. Secure children at six were more able to give a balanced view of themselves as good, but not perfect, while insecure children saw themselves as either faultless or bad. It should be noted that these results were much more consistent for the avoidant than the ambivalent group who gave very varied responses to the play tasks, without a clear pattern emerging. The disorganised group ('D') emerged more clearly in these as opposed to previous studies, showing bizarre or disorganized responses to picture- and story- completion tasks.
Main (1991) presents some remarkable preliminary findings of a follow-up study in which ten- and eleven-year-olds, who had been classified in the Strange Situation at one year, were asked for a spoken autobiography. There was a 75 per cent correspondence between classification at one and at ten. Compared with the insecurely attached, the secure children's stories were consistently more coherent, had greater access to memories, especially of their pre-school years, and showed more self-awareness and ability to focus in on their own thought processes, a phenomenon Main calls 'megacognitive monitoring' - the ability to think about thinking.
The findings so far, which represent more than a decade of 'post-Bowlbian' research into Attachment Theory, can be summarised as follows. Relationship patterns established in the first year of life continue to have a powerful influence on children's subsequent behaviour, social adjustment, self-concept and autobiographical capacity. These effects last for at least ten years. Mother-infant relationships characterised by secure holding (both physically and emotionally), responsiveness and attunement are associated with children who are themselves secure, can tolerate and overcome the pain of separation, and have the capacity for self-reflection.
These results undoubtedly support the view that the early years of life play a crucial part in character formation, and show in a fascinating way the continuity between the pre-verbal infant self
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and the social self as we commonly conceive it. But two important qualifications need to be noted. First, since the parent-child relationship operates continuously as development proceeds, what we are seeing is not so much the result of some irreversible early events as an ongoing relationship with its own 'epigenetic' stability. There is evidence that if a mother's circumstances change - for example, a single parent entering into a stable relationship with a partner - then attachment status for her child may change, in this case from insecure to secure. Similar changes can occur, as we shall see later in the chapter, when mother and infant are both treated with psychotherapy (Murray and Cooper 1992). Second, in presenting these findings the emphasis has been on the contribution of the parent, especially the mother, with the infant's role being relatively passive. Clearly this is a gross oversimplification, and temperamental, or even neurological, factors in the child will play their part in the relationship with the parent, and subsequent social adjustment. Attachment status is quite a crude classification and clearly there will be a spectrum of subtle characterological features within it. Nevertheless, the evidence seems to be that the parent is the determining factor and that a 'good' mother even with a 'difficult' baby will, by one year, be likely to have a securely rather than insecurely attached child. For example, the amount a child cries at one year seems to depend more on the mother than the child: there is a strong correlation between prompt and sensitive maternal responsiveness to infant crying in the first three months of life and reduced (as compared with children of less responsive mothers) crying at one year, whereas there is no correlation between the extent of infant crying itself in the first three months and the amount of crying at one year.
This leads us directly to the issue of the inter-generational transmission of attachment. If relationships are in some way internalised by the growing child as 'character', what happens when that child grows up and becomes a parent? We know from Harlow's (1958) experiments that infant monkeys separated from their mothers show, when they become sexually mature, gross abnormalities in mating and parenting behaviour. Can we trace in the infinitely more complex language- and experience-based world of the human primate, connections between a mother's capacity to provide secure attachment for her child, and her experiences with her own mother when she was a child?
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THE ADULT ATTACHMENT INTERVIEW
The Adult Attachment Interview (AAI) was devised by Main and her co-workers (1985) as a tool for assessing the working models or inner world of the parent with respect to attachment. It is a semi-structured interview conducted along the lines of a psychotherapy assessment aiming to 'surprise the unconscious' into self-revelation (Main 1991). The subject is asked to choose five adjectives which best describe the relationship with each parent during childhood, and to illustrate these with specific memories; to describe what she did when she was upset in childhood; to which parent she felt closer and why; whether she ever felt rejected or threatened by her parents; why she thinks her parents behaved as they did; how her relationship with her parents has changed over time; and how her early experiences may have affected her present functioning.
The interviews are audiotaped and then rated along eight scales: loving relationship with mother; loving relationship with father; role reversal with parents; quality of recall; anger with parents; idealisation of relationships; derogation of relationships; and coherence of narrative. The 'state of mind with respect to attachment' of the interviewees can then reliably be assigned to one of four categories: Autonomous-secure, Dismissing-detached, Preoccupied-entangled and Unresolved-disorganised.
The Autonomous-secure parents give accounts of secure childhoods, described in an open, coherent and internally consistent way. Attachments are valued, and even if their experiences have been negative there is a sense of pain felt and overcome. The Dismissing-detached group give brief, incomplete accounts, professing to having few childhood memories and tending to idealise the past with such remarks as 'I had a perfect childhood'. Preoccupied-entangled parents give inconsistent, rambling accounts in which they appear to be overinvolved with past conflicts and difficulties with which they are still struggling. The Unresolved-disorganised category is rated separately and refers specifically to traumatic events such as child abuse which have not been resolved emotionally.
Several independent studies have shown remarkably consistent correlations between the attachment status of infants in the Strange Situation, and that of their mothers in the AAI. A number of retrospective studies have shown a 70-80 per cent correspondence
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between infant security and parental attachment status on the AAI. Thus Main and Goldwyn (1984) found that 75 per cent of secure infants had mothers who were rated Secure-autonomous, while mothers of avoidant infants tended to be Dismissing- detached, and ambivalent infants had Preoccupied-entangled parents. The Grossmans found 77 per cent correspondence, and Ainsworth 80 per cent. Even more striking are the findings of Fonagy and his co-workers (Fonagy et al. 1991), who administered the AAI to prospective parents during pregnancy and found that the results predicted infant attachment status in the Strange Situation at one year with 70 per cent accuracy. Of insecure infants 73 per cent had insecure mothers, and only 20 per cent of secure infants had insecure mothers, while 80 per cent of secure mothers had secure infants. The influence of fathers appeared to be less: 82 per cent of secure fathers had secure infants, but 50 per cent of insecure fathers still had secure infants. This supports the view that attachment status is a function of the infant-parent relationship, rather than of temperament, and also suggests that maternal, rather than paternal, insecurity is the more potent transmitter of insecure attachment across the generations.
Prospective findings were less clear-cut for the preoccupied parent-ambivalent infant correlation. Many ambivalent children had mothers who were apparently secure when given the AAI in pregnancy. However, Fonagy et al. (1992), on reviewing these interviews, found evidence of a certain 'fragility' in the replies of these mothers, suggesting a tendency to idealisation which could easily be mistaken for security. There is some evidence that ambivalent children may have shown physiological immaturity at birth, or are the products of difficult labours, and it is possible that immaturity in the infant may have exposed the mother's 'fragility' in such a way as to produce an ambivalent attachment status at one year.
THEORETICAL INTERLUDE
The findings of this new generation of post-Bowlbian researchers are summarised in Table 6. 1 and produce a coherent picture of benign and vicious cycles of security and insecurity. Secure mothers are responsive and attuned to their babies and provide them with a secure base for exploration. They are able to hold them, delight in them, and cope with their discontent and aggression in a
Table 6. 1 The continuity of secure and insecure attachment
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satisfactory way. These mothers have a balanced view of their own childhoods which, even if unhappy, are appraised realistically. Their children, secure as infants, grow up to be well-adjusted socially and to have a realistic self-appraisal and a sense that separation, although often sad and painful, can be responded to positively. Secure mothers and secure children have a well- developed capacity for self-reflection and narrative ability, and convey a sense of coherence in their lives.
Insecure children, by contrast, especially if avoidant, tend to have mothers who found holding and physical contact difficult, who were unresponsive to their infant's needs and not well attuned to their rhythms. These mothers tended to be dismissing about their relationships with their parents and to be unable to tell a vivid or elaborated story of their own childhoods. As they grow up, avoidant children tend to be socially isolated, to show unprovoked outbursts of anger, to lack self-awareness and to be unable to tell a coherent story about themselves.
Are we seeing in these insecure children the roots of adult personality difficulty and neurosis? If so, what can we learn about the mental mechanisms that may underlie these disorders, and do they provide clues as to how psychotherapy might help to reverse them? We shall discuss in the next two chapters the parallels between avoidant strategies in infancy and some of the features of borderline personality disorder, and the possible links between phobic and dependency disorders in adults and patterns of ambivalent attachment in infancy. Our concern here is to try to conceptualise how maternal handling becomes internalised as infant psychology. In Fraiberg's (Fraiberg et al. 1975) telling metaphor: 'In every nursery there are ghosts. These are the visitors from the unremembered pasts of the parents; the uninvited guests at the christening. ' How do the parental ghosts get incorporated into the internal working models of the infant? Three inter-related ideas can be used to clarify this: avoidance of painful affect (Grossman and Grossman 1991), consistency and coherence of internal working models (Bretherton 1991a), and self-reflection (Fonagy 1991; Fonagy et al. 1991, 1992).
As we have seen in the previous chapter, Bowlby views the capacity to 'process' negative affect - to feel and resolve the pain of separation and loss - as a central mark of psychological health. Parents of insecure infants fail to respond appropriately to their infant's distress, either ignoring it (avoidants) or becoming over-
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involved, panicky and bogged down in it (ambivalents). It seems possible that because these parents have not been able to deal with or 'metabolise' (Bion 1978) their own distress they cannot cope with pain and anger in their infants and so the cycle is perpetuated. The infant is faced with parents who, due to their own internal conflicts or ego weakness, cannot hold (Winnicott 1971) the child's negative feelings of distress or fear of disintegration. The child is therefore forced to resort to primitive defense mechanisms in order to keep affects within manageable limits.
Thus the essential factor which all these separations have in common is that, during the early development of his object- relationships, the child is suddenly removed and placed with strangers. He is snatched away from the people and places which are familiar and whom he loves and placed with people and in surroundings which are unknown and alarming.
(Bowlby 1944)
This must have struck many a sympathetic chord in readers who had survived six years of wartime evacuation, enforced separation and bereavement.
The second factor connecting delinquency and the 'affectionless character' with separation was the 'inhibition of love by rage and the phantasies resulting from rage'. The separated child responds to the absence of his parent with feelings of fury and destructiveness. Normally, as Klein and later Bion described, the soothing presence of the parent would enable these phantasies to be modified by reality, and therefore to give up their dominance in the child's mind. But if the mother is absent, or is herself aggressive and liable to retaliate rather than accept her child's anger, the growing child may be left harbouring phantasies of revenge and hatred which then become manifest in delinquent behaviour. This may be accompanied by an indifference born of
[the] determination at all costs not to risk again the disappointment and resulting rages and longings which wanting someone very much and not getting them involves . . . a policy of self-protection against the slings and arrows of their own turbulent feelings.
(Bowlby 1944)
We see in this early work the prefigurings of three of Bowlby's most insistent themes: the centrality of loss as a determinant of disturbance, the importance of the mother in neutralising and defusing the destructive effects of rage in response to loss, and the use of affective withdrawal as a defense against the pain of unmet longing or anger faced alone. Bowlby had already identified
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the importance of expression of anger, rather than its repression, and the role of the parents in fostering or holding this back, in his pre-war study of aggression:
Take the child away from the fire, deny it a second piece of cake, but avoid being angry or hurt or disapproving if a scream of rage or a kick on the shins is the immediate consequence of thwarting a child's will to happiness. To permit children to express their feelings of aggression, whilst preventing acts of irremediable destruction is, we suggest, one of the greatest gifts that parents can give to their children.
(Durbin and Bowlby 1938)
As we saw in Chapter 3, Bowlby's own retrospective findings were buttressed by his review of the world literature on the effects of separation, and here too he emphasises the importance of active protest as a mark of a positive response to separation: 'a violent reaction is normal and an apathetic resignation a sign of unhealthy development' (Bowlby 1965).
PROSPECTIVE STUDIES: CHILDREN IN HOSPITAL
Together with James Robertson (Robertson and Bowlby 1952b), Bowlby was next able to establish by direct observation the effects on children of temporary separation from their parents. They studied the reactions of children who were taken into hospital, which in those days required almost complete absence of contact with parents during the admission (for fear of cross-infection), and a series of constantly changing carers in the hospital ward. Profound effects were noted,especiallyintheyoungeragegroups. Thechildreninitiallybecametearful, crying and calling bitterly for their parents, and rejecting the staff's attempts to mollify or distract them. Later, bored indifference and apathy seemed to take over, with the children isolating themselves from their peers, sitting listlessly staringintospace,playingandeatinglittle. Finally,childrenappearedto'recover' and to become active once more, but if hospitalisation was prolonged their relationshipswithadultsandotherchildrenappearedsuperficialandself-centered compared with before.
These three phases were described by Bowlby as the stages of protest, withdrawal and detachment. Feelings of protest reemerged when these separated children were reunited with their parents, who were subjected to a mixture of rejection (even to the point of failing to recognise them), angry attacks and clinging in the days following return from hospital.
Loss, anger and grief 89
Some of these changes were long-lived and could be detected up to two years later. They also found that the effects of separation could be mitigated by a number of common-sense measures including regular hospital visiting by parents, preliminary reconnaissance visits to the hospital ward, allowing children to take familiar comforting objects like teddy-bears with them when they went into hospital, and in the case of separations not involving hospital, placing them with adults who were previously known and trusted. All of these moves have by now become part of routine parental and pediatric practice.
AN ANATOMY OF MOURNING
The 1960s saw two important developments in the understanding of the psychological impact of loss. First, Bowlby was joined at the Tavistock by Colin Murray Parkes who undertook a systematic study of bereavement in adults which complemented and confirmed Robertson's (1952) earlier work with children (Parkes 1975). Second, the crystallisation of Attachment Theory provided a theoretical basis on which to understand these empirical findings.
Bowlby's theory of bereavement is essentially an extension of his theory of separation anxiety which we have considered in the previous chapter. He sees anxiety as realistic response to separation or threatened separation of a vulnerable individual from his care- giver. Since care-seeker and care-giver form a reciprocal partnership, and since the attachment dynamic continues throughout adult life, separation anxiety will arise whenever the parent-child, adult-spouse or adult-companion relationship is threatened. The components of separation anxiety include a subjective feeling of worry, pain and tension; angry protest, whose function is to register displeasure and to punish the errant partner so as to prevent repetition; and a restless searching for the missing person.
Bowlby sees the grief reaction as a special case of separation anxiety, bereavement being an irreversible form of separation. He believes that the psychological response to the trauma of separation is biologically programmed in the same way that the inflammatory response is an orderly sequence of physiological responses to physical trauma - redness, swelling, heat and pain. The early phases of grief consist of an intense form of separation anxiety. The later phases result from the confusion and misery that arise from the realisation that the secure base to whom the
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bereaved individual would turn for comfort in distress is the very person who is no longer available. With this in mind, let us look now at the four phases of mourning (Bowlby 1980, 1982a, 1988a) in more detail.
Stage 1: numbing
A soldier wounded on the field of battle may feel no pain and continue to fight until help is at hand. In the same way, perhaps, the very earliest response to a sudden bereavement may be an apparent calmness based on emotional shutdown in which all feelings are suppressed, or reality denied, until the bereaved person is in a safe enough situation to let go a little.
A bereaved wife in the casualty department
A young scaffolder was brought into the casualty department dead, having fallen from a tall building. There were no external signs of injury. When his wife arrived she was completely and chillingly calm, expressing no emotion, simply saying: 'Oh, but he's not dead, he's asleep, doesn't he look beautiful and peaceful. ' It was only when, several hours later, her mother arrived that she began to sob and wail uncontrollably.
Stage 2: yearning, searching, anger
Bowlby places the search for the lost object at the centre of the mourning response. There may be physical restlessness and wandering as the bereaved person goes from room to room, from place to place, scanning, looking, hoping that their lost loved one may reappear. A similar process goes on psychologically in which the bereaved person goes over in their mind every detail of the events leading up to the loss, in a kind of compulsive 'action replay', hoping that some mistake may have been made and that past events can be made to turn out differently.
Freud (1917) saw the purpose of this mental searching as that of detachment: 'Mourning has a quite precise psychical task to perform: its function is to detach the survivor's memories and hopes from the dead. ' Bowlby, by contrast, sees purpose in evolutionary rather than teleological terms, and views the mental
Loss, anger and grief 91
searching of the bereaved as an attempt to recover and be reunited with the lost object. Similarly, Bowlby's understanding of the prevalence of visual images of the dead person that so often haunt the bereaved is of an intense 'perceptual set' towards the sight and sound of the lost person that can lead to misinterpretation of auditory and visual clues. Just as the 3-month-old infant quickens at the sound of his mother's footsteps and scans his visual field anxiously until he can meet her greeting smile with his, so the bereaved person is desperately trying to track down his missing attachment figure. Following Darwin (1872), Bowlby sees the facial expressions and crying of the bereaved as a resultant of the tendency to scream in the hope of awakening the attention of a negligent care-giver, and the social inhibition of such screaming.
Anger too is part of the normal response to separation: 'almost every separation has a happy ending, and often a small or large dash of aggression will assist this outcome' (Bowlby 1961c). Bowlby emphasises again and again the importance of the expression of anger if the bereaved person is to recover:
Only if he can tolerate the pining, the more or less conscious searching, the seemingly endless examination of why and how the loss occurred, and anger at everyone who might be responsible, not even sparing the dead person, can he gradually come to realise and accept that loss is in truth permanent and that his life must be shaped anew.
(Bowlby 1982a)
The anger so often seen towards potential comforters whose aim is to help the bereaved person 'come to terms' with the loss, or towards doctors responsible for the care of the dead person, can be understood in this light too. They represent the loss of hope that the loved one might somehow be alive. Their cold comfort can trigger an angry outburst in one who, already weakened by the stress of loss, wants nothing less than to be reminded that the loss is indeed irrecoverable. If only someone can be blamed then this allows the 'secret hope
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that perhaps in some miraculous way to seek out the villain will lead to recovery of loss' (Bowlby 1961c).
The lonely widow
Marion was fifty-five when her husband died suddenly of a heart attack. Childless, they had been married for thirty years and had returned to the United Kingdom after years of living overseas, having lost all their possessions in a fire. Marion had relied on her husband for everything, sheltering behind his competence and social confidence. She 'coped' well at first after his death, but then was admitted to hospital after taking a large overdose. She had only been found in time because the milkman had noticed uncollected bottles and raised the alarm. When she recovered she explained how furious she had felt when her doctor (who had failed in her eyes to save her husband's life) had summoned her for a cervical smear test, without apparently realising that she had had a hysterectomy some years previously.
Therapy with her meant withstanding a torrent of fury about the unfairness of life. She blamed the doctors, the laxity of modern society (the England she had returned to was such a different place from the one she had left), the insurance companies, the Government - everyone. She agreed reluctantly to try not to kill herself, although she continued to insist that life without her husband was futile and meaningless. Contrary to expectation, exploring her childlessness, of which the GP's summons had reminded her, did not lead to feelings of sadness about her lack of children. Instead she revealed how she, unlike her husband, had never wanted children since she feared that this would divert his care and attention from her, as she felt had happened with her mother in her family (she, like Bowlby's mother, was the oldest of six) when her younger siblings were born. A history of excessive dependency and exclusive monotropism is a significant predisposing factor towards prolonged grief reactions (Parkes 1975).
Stages 3 and 4: disorganisation and despair: reorganisation
The diagram of the attachment relationship (Figure 4. 1) shown in the previous chapter depicted a dynamic equilibrium between
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care-seeker and care-giver, constantly monitored, quiescent at times of exploration, activated at times of stress. Bowlby (1980) likens the shock of loss to a see-saw in which one person is suddenly removed, and quotes C. S. Lewis on his widowerhood: 'So many roads once; now so many culs-de-sac. ' The basic dilemma of the bereaved is, as we have said, that the loss removes not only the loved one, but also the secure base to which the bereaved person would expect to turn in their hour of need.
Loss throws the inner world of the sufferer into turmoil. All the assumptions and expectations which depended on the presence of the loved one are now thrown into question. Where can the bereaved person find hope and comfort in the face of his inner turmoil and confusion? The quasi-depressive state which marks the third stage of grief can be understood in a number of ways. Freud (1917) recognised that some internal work was occurring which was necessary before the person could begin to form new attachments. For him the key feature was identification with the lost object; in Klein's (1986) word, the lost person is 'reinstated' in the inner world in the course of healthy grief so that he or she forms part of a composite internal representation of reality.
Melanie Klein (1986) sees the depression and apathy and withdrawal of the bereaved as a regression to infancy, a result of the assault on the security of the inner world which has been so painstakingly built up through childhood. For Klein grief is 'shot through with persecutory anxiety and guilt' (Bowlby 1961a) because the bereaved person is thrown back to the abandonments and failures of early childhood. During the phase of disorganisation the bereaved person is constantly questioning and questing, but 'reality passes its verdict - that the object no longer exists - upon each single one of the memories and hopes' (Klein 1986). Just as the infant, through maternal tolerance and capacity to process conflict and negative affect learns that the lost breast will reappear, that his anger has not destroyed his mother's love, so the bereaved person begins once more to build up his inner world:
every advance in the process of mourning results in a deepening in the individual's relation to his inner objects, in the happiness of regaining them after they were felt to be lost. This is similar
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Attachment Theory
to the way in which the young child step by step builds up his relation to external objects, for he gains trust not only from pleasant experiences, but also from the ways in which he overcomes frustrations and unpleasant experiences, nevertheless retaining his good objects.
(Klein 1986)
Bowlby is critical of Klein for what he sees as her overemphasis on the persecutory aspect of normal (as opposed to abnormal) grief, and for her neglect of the reality of the danger to which the bereaved person is exposed (widowers die of a broken heart more frequently than comparable non-bereaved men). Nevertheless, her account of the impact of death on the internal world is entirely compatible with the Bowlbian view that the work of grief consists of rebuilding a secure inner base, that the building of secure attachment depends on a secure holding environment which in the past has been reliable enough to withstand and process hostility, and that new attachments can only be formed once old ones are relinquished.
A widower - at twenty-six
Jock was a tough shipbuilder from the Clyde. At twenty-six his wife died suddenly of a cerebral haemorrhage, leaving him with six children aged eight to 6 months. He tried for a few weeks to carry on as normal but suddenly took all the children to his sister and brother-in-law and set off for London. There he led the life of a tramp, living on the streets and in doss houses, drinking heavily, fighting a lot and moving on. Eventually he was brought to the emergency clinic of the hospital, where he told his story. He spoke of his feelings of rage and fury towards his wife for abandoning him, about which he felt intensely guilty and about his incomprehension that God (he was a devout Catholic) should have allowed such a thing to happen to him; of the despair and chaos which he felt inside; of his wish to smash anyone and everyone who thwarted or tried to control him; and of his need to drink to blot out the pain of losing the wife whom he loved so much. His drinking and way of life continued, but he went on coming to the clinic to talk. Then, suddenly and without warning he disappeared. A few weeks later he wrote saying that he had returned to Glasgow, had stopped drinking and was now happily looking after the children. A further letter about a year later confirmed that things continued to go well.
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Perhaps Jock felt sufficiently 'held' (in the Winnicottian sense) by his weekly contact with the therapist at the hospital to be able to rebuild his inner world so that he could become once more a secure base for his children - leaving his therapist as abruptly as his wife had 'left' him. For Bowlby the opportunity for emotional release is an essential ingredient in healthy mourning, avoiding the defensive manoeuvres which unexpressed emotion requires:
The behaviour of potential comforters plays a large part in determining whether a bereaved person is sad, perhaps dreadfully sad, or becomes despairing and depressed as well . . . if all goes well, since he will not be afraid of intense and unmet desires for love from the person lost, he will let himself be swept by pangs of grief and tearful expressions of yearning, and distress will come naturally.
(Bowlby 1982a)
MOURNING AND ADULT PSYCHOPATHOLOGY
Bowlby's early studies had convinced him of the far-reaching effects of separation and bereavement in childhood. He was convinced that much of adult psychiatric disability could be traced back to such traumata. This view is supported by recent psychophysiological findings that early separation can have long- lasting effects on the sensitivity of brain receptors, leading to permanently raised anxiety levels (Van de Kolk 1987; Gabbard 1992). Post (1992) has similarly argued that depression in adult life may originate with environmental trauma that is encoded in brain changes in protein and RNA, on the analogy of the 'kindling' phenomenon in epilepsy in which the sensitivity of brain cells becomes progressively greater with each seizure, so that what starts as a response to an environmental stimulus becomes eventually an intrinsic feature of the brain.
Bowlby was also convinced that the response of the adult world to a child's distress had a decisive influence on the outcome of loss. He was implacably opposed to the stiff- upper-lip attitude, and disparagement of 'childishness' which epitomised his generation, class and profession. Love, tenderness, encouragement of emotional expression even if hostile, and acceptance of the lifelong imperative for mutual dependency were his watchwords.
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Recent epidemiological research (Tennant 1988) suggests that the influence of childhood bereavement per se on adult psychiatric disorder is probably less significant than Bowlby imagined. Parental disruption and disturbance is a much more potent cause of difficulty and depression than loss in itself. But, as we shall see in Chapters 6 and 9, the current evidence suggests that Bowlby was right to emphasise the real nature of environmental influence and to make quite sharp distinctions between normal and abnormal developmental patterns, a point which he felt the psychoanalysts consistently fudged. His hunch that loss was a key research issue has been proved right, but in a more subtle way than he might have imagined, and one which is compatible with the Kleinian view from which he was so careful to distance himself. The manner in which a child's carers respond to her or his reactions to loss, whether major or minor - to the anger and pining and demandingness - may crucially influence that child's subsequent development. The establishment of a secure internal base, a sense that conflict can be negotiated and resolved, the avoidance of the necessity for primitive defences - all this depends on parental handling of the interplay between attachment and loss that is the leitmotiv of the Bowlbian message.
COMPANIONSHIP AND ATTACHMENT: A POETIC POSTSCRIPT
Being highly intelligent, very well-organised and slightly obsessional, Bowlby was a master of any topic to which he put his mind: for example, he re-read the whole of Freud during his Stanford fellowship in 1957. The corollary of this was that he tended to avoid those few subjects of which he had only passing or partial knowledge, one of which was English literature (U. Bowlby 1991). Having no such scruples - perhaps to my discredit - I conclude this chapter by considering three classic poems of grief from the English canon, which in their non-scientific way lend some support to Bowlby's thesis on mourning.
Milton's Lycidas and Tennyson's In Memoriam are both poems by young men about the loss of loved and valued fraternal comrades. It is debatable whether friendship (and sibship) fulfil the criteria of proximity seeking, secure-base effect and separation protest which are the hallmarks of a full-blown attachment relationship. Weiss (1982) distinguishes the companionship provided by friends from the intimacy of adult attachment typically to be found in a sexual
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partnership. He showed how wives who move because of their husband's job to new towns felt cut off from their friends and bored, but did not experience the specific empty loneliness that widows or separated people feel when loss of a spouse first hits. Similarly, Heard and Lake (1986) write about the need for 'like- minded companions of similar experience and stamina with whom to engage in mutually interesting and enjoyable activities' as part of the 'attachment dynamic'. A cursory glance at any lonely hearts column will attest to the reality of this need. The prime role of friendship seems to facilitate exploratory activity rather than to provide a secure base, although without a secure base no exploration is possible, and many intimate relationships, especially marriage, provide both. It seems likely that friendship or sibship does have a more central role as a source for a secure base in certain circumstances: in adolescence; among comrades in intense and isolated circumstances such as the armed services or mountaineering expeditions; and between siblings when the parental relationship is difficult or defective. The latter was certainly the case for Tennyson, who had an extremely unhappy and tormented childhood which he survived mainly through his writing and intelligence (Hamilton 1986), and, from his teenage years, through his friendship with Arthur Hallam who, although two years younger, became his mentor, sponsor and champion. Hallam's premature death when Tennyson was only twenty-four led to near- breakdown for the poet. In Memoriam was started within weeks of the loss, but was only completed and published some thirteen years later.
Milton's Lycidas 'bewails' the death of a 'learned friend' (Edward King) drowned in the Irish Sea - like Tennyson's Hallam, a childhood companion and one who shared Milton's radical anti-clericalism. Milton's mother had died a few months earlier; numbed, Milton had apparently been unable to write anything to mark her loss. The scene is pastoral and the two friends are depicted as shepherds. The need at times of grief to return to the good object (breast-hill) is evoked:
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For we were nursed upon the self-same hill, Fed the same flock by fountain, shade, and rill.
The centrepiece of the poem is the attack on the 'corrupted clergy then in their height', drawn as self-serving, ignorant shepherds. Like so many prematurely bereaved people, Milton rails against the injustice of fate: why has my loved one died, who did not deserve it, and not those undeserving souls who live on?
'How well could I have spared for thee, young swain, Enow of such as for their bellies' sake
Creep, and intrude, and climb into the fold! . . .
Blind mouths! that scarce themselves know how to hold A sheep-hook . . .
The hungry sheep look up, and are not fed,
But swoln with wind, and the rank mist they draw, Rot inwardly, and foul contagion spread. '
The inner world is contaminated and fouled by the anger and despair of the poet, then projected onto the corrupt priests who are held to blame for the loss.
The action of the poem takes place in a single night in which the poet passes through the stages of sadness, despair, anger, blame and depression until he reaches acceptance, with the help of two images from the natural world. The first are the garlands of flowers with which to 'strew the laureat hearse where Lycid lies', and which serve to link the loss of Lycidas with the natural transience of beauty. In the second he pictures the sun setting over the ocean where Lycidas is drowned, only to rise again the next morning,
and with new spangled ore
Flames in the forehead of the morning sky.
An image of setting and rising, of separation and reunion, has replaced the sense of irretrievable loss. A secure base is reestablished, mirroring perhaps the regular appearance and disappearance of the feeding mother. The poet can begin once more to explore, no longer enshrouded, but enveloped by a cloak that moves and lives:
At last he rose, and twitched his mantle blue: To-morrow to fresh woods and pastures new.
In In Memoriam we see many of the same themes. In recalling his love for Hallam, Tennyson is taken back to pre-verbal
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paradisial times before the loss, reminiscent of the mother's attunement to her baby's needs, which leads, in Winnicottian terms, to the opening out of a transitional space between them. The poet describes the two friends' sense of intuitive, empathic understanding:
Dear as the mother to the son More than my brothers are to me . . .
Thought leapt out to wed with Thought Ere thought could wed itself with speech.
But then the dreadful boat brings the dead body home. Tennyson contrasts his own empty hands and those reunited with their attachment figures:
Thou bring'st the sailor to his wife
And travelled men from foreign lands And letters unto trembling hands
And, thy dark freight, a vanished life.
Tennyson tackles the tragic implications of monotropism: attachments are not transferable, or only so by a slow and painful process of withdrawal and re-attachment. By contrast, nature becomes an indifferent mother who cares equally and indiscriminately for all her 'children' and has no special affection for any one of them.
Are God and Nature then at strife,
That Nature lends such evil dreams? So careful of the type she seems,
So careless of the single life?
Despair strikes, meaning is destroyed, when the interplay of attachment, with its mutual reinforcement, its linking of inner world and outer reality is disrupted:
'So careful of the type'? But no.
From scarped cliff and quarried stone She cries, 'A thousand types are gone;
I care for nothing, all shall go. '
Loss throws us back to our childhood, to our primary attachments:
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but what am I?
An infant crying in the night: An infant crying for the light:
And with no language but a cry.
Tennyson begins to think on a new time-scale and to see the possibility of new attachments, as one generation succeeds another:
Unwatch'd, the garden bough shall sway, The tender blossom flutter down . . .
Till from the garden and the wild
A fresh association blow,
And year by year the landscape grow
Familiar to the stranger's child.
Finally he returns to the image of mother and child, to the hatching of individuality from their symbiotic mixed-upness (Balint 1964). The mother's 'roundness' takes him round the corner of his developmental pathway towards a less despairing separation in which the inner world is strengthened and clarified:
The baby new to earth and sky
What time his tender palm is prest Against the circle of the breast
Has never thought that 'this is I'
So rounds he to a separate mind
From whence clear memory may begin As through the frame that binds him in
His isolation grows defined.
So it is with grief where, if all goes well, can come a strengthening of the inner world, of memory and definition. As we shall argue in Chapter 8, the importance of telling a story, of 'clear memory' is central to the poet's (and the psychotherapist's) mission.
John Donne's 'A Valediction: forbidding mourning' also concerns a sea voyage, and also uses the image of a 'round' or circle as an antidote to the abyss of loss and separation. This is a poem about anticipatory grief, given by Donne to his wife before setting sail for France in November 1611 (Gardner 1957).
He starts by advocating a slipping away on parting, which he compares with death, rather than an abrupt and emotional separation:
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As virtuous men pass mildly away,
And whisper to their soules to goe Whilst some of their sad friends doe say
The breath goes now, and some say no.
He contrasts their love which that of 'dull sublunary lovers', who lack a secure inner base and who therefore are dependent on one another's physical presence. They
cannot admit
Absence, because it doth remove
Those things which elemented it. But we . . .
Interassured of the mind,
Care lesse, eyes, lips, and hands to misse.
He pictures the invisible but precious bonds which link carer and cared-for, lover and beloved in an attachment relationship as slender threads of gold:
Our two souls therefore, which are one, Though I must goe, endure not yet A breach, but an expansion,
Like gold to ayery thinnesse beate.
Then, in another brilliant metaphysical metaphor, he imagines the internal working model of self and other as the two ends of a pair of compasses:
Thy soule the fixt foot, makes no show To move, but doth, if th'other doe.
And though it in the center sit,
Yet when the other far doth rome,
It leanes, and hearkens after it,
And growes erect, as it comes home. . .
Thy firmnes makes my circle just,
And makes me end, where I begunne.
We have mentioned how Bowlby says little about sexuality and is at pains to separate 'mating behaviour' from 'attachment behaviour'. The sexual imagery of this poem - despite appearances to the contrary ladies do move, perhaps 'grow erect' even, the
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lover 'ending' (that is, in orgasm) where he 'begun' (namely, was born) - combines in a profound way sexuality and attachment. The rhythm of sexuality, of coming together and separating, is linked both with death and the parting of soul from body at the start of the poem, and with birth at the end. They are held together by the central image of the secure base or 'inter-assurance' of lover and beloved. Seen in this way, attachment is a unifying principle that reaches from the biological depths of our being to its furthest spiritual reaches.
The inevitability of loss means that for Bowlby grief sometimes outshines attachment in importance, that his criticisms of psychoanalysis sometimes outweigh his praise, just as for the republican Milton, Satan and the underworld were more vibrant and interesting than the kingdom of God.
Chapter 6
Attachment Theory and personality development: the research evidence
It is just as necessary for analysts to study the way a child is really treated by his parents as it is to study the internal representations he has of them, indeed the principal form of our studies should be the interaction of the one with the other, of the internal with the external.
(Bowlby 1988a)
One of Bowlby's main reasons for re-casting psychoanalysis in the language of Attachment Theory was the hope that this would make it more accessible for empirical testing. This hope has been fully justified. The past thirty years have seen an explosion of research in infant and child development, a major part of which has arisen directly from the work of Bowlby and Mary Ainsworth in the 1950s and sixties. The aim of this chapter is to show how these findings point to aremarkablyconsistentstoryabouttheemergenceofpersonality,or'attachment style', out of the matrix of interactions between infant and care-givers in the early months and years of life. The issue of how what starts as interaction becomes internalised as personality is a key question for developmental psychology. Object-Relations Theory rests on the assumption that early relationships are a formative influence on character. I hope to demonstrate in this and the following chapter that Bowlby's movement away from psychoanalysis has come full circle and produced ideas that are highly relevant to,andprovidestrongsupportandenrichmentfor,thepsychoanalyticperspective.
As a scientific discipline, Attachment Theory has two great advantages over psychoanalysis. First, it rests on direct observation of parent-child interaction, rather than on retrospective
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reconstructions of what may or may not have gone in a person's past. Second, it starts from the observation of normal development, which can then be used as a yardstick against which to understand psychopathology, rather than building a theory of normal development from inferences made in the consulting room. It is perhaps no accident that the psychoanalyst with whom Bowlby has most in common, Winnicott, was also keenly aware of normal developmental processes through his earlier work as a pediatrician. Winnicott and Bowlby both believed that their observations of normal development were relevant to psychotherapy, for by getting a picture of what makes a good parent, we are likely to be in a better position to know what makes a good psychotherapist.
MARY AINSWORTH AND THE STRANGE SITUATION
There is an intimate relationship between technology and scientific advance. Galileo's observations depended on the expertise of the sixteenth-century Italian lens grinders; Darwin's discoveries sprang from the navigational and cartographic skills of Victorian maritime imperialism. Ainsworth's 'Strange Situation', 'a miniature drama in eight parts' (Bretherton 1991a) for mother, one-year-old infant and experimenter, has established itself as an indispensable tool in developmental psychology.
Ainsworth devised the Strange Situation in the late 1960s as part of her studies of mother-child interaction in the first year of life. She had worked with Bowlby in the 1950s, then moved to Uganda where she had made naturalistic studies of mothers with their babies, and finally settled in Baltimore, Maryland. Influenced by Attachment Theory, although at first wary of its ethological bias, she was interested in the relationship between attachment and exploratory behaviour in infants, and wanted to devise a standardised assessment procedure for human mothers and their children which would be both naturalistic and could be reliably rated, comparable to the methods used by animal experimenters like Harlow (1958) and Hinde (1982b).
The Strange Situation (Ainsworth et al. 1978) consists of a twenty-minute session in which mother and one-year-old child are first introduced into a playroom with an experimenter. The mother is then asked to leave the room for three minutes and to return, leaving the child with the experimenter. After her return
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and the re-union with the child, both mother and experimenter go out of the room for three minutes, leaving the child on its own. Mother and child are then once more re-united. The whole procedure is videotaped and rated, focusing particularly on the response of the child to separation and re-union. The aim is to elicit individual differences in coping with the stress of separation. Initially three, and later four, major patterns of response have been identified:
1. Secure attachment ('B') These infants are usually (but not invariably) distressed by the separation. On re-union they greet their parent, receive comfort if required, and then re- turn to excited or contented play.
2. Insecure-avoidant ('A') These children show few overt signs of distress on separation, and ignore their mother on re-union, especially on the second occasion when presumably the stress is greater. They remain watchful of her and inhibited in their play.
3. Insecure-ambivalent (insecure-resistant) ('C') They are highly distressed by separation and cannot easily be pacified on re- union. They seek contact, but then resist by kicking, turning away, squirming or batting away offered toys. They continue to alternate between anger and clinging to the mother, and their exploratory play is inhibited.
4. Insecure-disorganised ('D') This small group has recently been demarcated. They show a diverse range of confused behaviours including 'freezing', or stereotyped movements, when re-united with their parent.
In Ainsworth's original middle-class Baltimore sample the proportions were 'B' (secure) 66 per cent, 'A' (avoidant) 20 per cent, and 'C' (ambivalent) 12 per cent. 'D' had not been identified at that stage. Since her original publication, the Strange Situation has been used in well over thirty different studies (Ijzendoorn and Kroonenberg 1988), and is generally accepted as a reliable and valid instrument - comparable perhaps to the widespread use of the Expressed Emotion scales in psychiatry (Left and Vaughn 1983; see Chapter 9). There are significant cross-cultural variations, so that 'A' (avoidant) classifications tend to be commoner in Western Europe and the United States, while 'C' (ambivalent) is commoner in Israel and Japan. Intra-cultural
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variation between different socio-economic groups and between disturbed and non-disturbed families is greater than inter-cultural variance.
A whole set of research and theoretical questions follows from the establishment of this robust research tool. What is the meaning of the different patterns of response? Are they stable over time, and if so for how long? Do they predict disturbed behaviour later in childhood? Do they, as psychoanalytic theory might assume, persist into adult life? Can they be related to patterns of maternal- infant interaction in the early months of life? If maternal handling is relevant to classification pattern, what is the relationship between this and the mother's own experience of being mothered? If so, what are the psychological mechanisms by which attachment patterns are carried over from one generation to the next? Can patterns be altered by therapeutic intervention? The remainder of this chapter will be devoted to a discussion of these and related questions.
THE ROOTS OF SECURE AND INSECURE ATTACHMENT
Bowlby saw personality development primarily in terms of environmental influence: relationships rather than instinct or genetic endowment are primary. Differing patterns of attachment result from differing patterns of interaction, rather than being a reflection of infant temperament, or instinct. Sroufe (1979) makes an important distinction between 'emergent patterns of personality organisation' as revealed in the Strange Situation, and temperament, the latter representing quasi-physiological styles of behaviour, while the former reflect much more complex habitual relationship patterns. Thus babies may be sluggish, or active, 'cuddly' or non-cuddly, slow or fast, but still be classified as secure. Even more telling is the finding that children have different, but characteristic, attachment patterns with their two parents, and may be classified as secure with one and insecure with the other. This argues strongly that attachment patterns are a feature of the parent-child relationship, as yet not 'internalised' at one year, although by 18 months patterns have become more stable, with maternal patterns tending to dominate over paternal.
The Strange Situation research was part of a much larger study in which Ainsworth and her colleagues visited mothers and their
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infants regularly for periods of observation and rating during the whole of the first year of life. She found that attachment status at one year correlated strongly with the maternal relationship in the preceding twelve months, and this finding has been replicated in several other centres (Main and Weston 1982; Grossman et al. 1986; Sroufe 1979). In summary, prospective studies show that mothers of secure one-year-olds are responsive to their babies, mothers of insecure-avoidants are unresponsive, and mothers of insecure-ambivalents are inconsistently responsive.
The key to secure attachment is active, reciprocal interaction (Rutter 1981), and it seems that it is quality of interaction more than quantity that matters - a finding that contradicts Bowlby's earlier view on the causes of maternal deprivation. Passive contact alone does not necessarily promote attachment. Many babies are strongly attached to their fathers even though they spend relatively little time with them, and kibbutzim-reared children are more strongly attached to their mothers than to the nurses who feed them and look after them during the day, but often without much active interaction. In the first three months, mothers of secure infants respond more promptly when they cry; look, smile at and talk to their babies more; and offer them more affectionate and joyful holding. Mothers of avoidant children tend to interact less, and in a more functional way in the first three months, while mothers of ambivalents tend to ignore their babies' signals for attention and generally to be unpredictable in their responsiveness. By the second half of the first year, clear differences can be detected in the babies, and those who will be classified as secure at one year cry less than the insecure group, enjoy body contact more, and appear to demand it less (Bretherton 1991b).
The factor which mothers of insecurely attached children have in common can be understood in terms of Stern's (1985) concept of maternal attunement. He shows how sensitive mothers interacting with their children modulate their infant's rhythms so that when activity levels fall and the infant appears bored the mother will stimulate them, and when the child becomes overstimulated the mother will hold back a little so as to restore equilibrium. In cross-modal attunement the mother follows the baby's babbling, kicking, bouncing and so on with sounds or movements of her own that match and harmonise with those of the baby, although they may be in a different sensory mode. As he bounces up and down she may go 'Oooooh . . . Aaaaah . . . ',
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matching the tempo and amplitude of her responses to the baby's movements. This helps, as Stern sees it, in the development of the infant's sense of integrated selfhood. These processes of attunement are impaired in mothers of insecurely attached infants, leading to 'derailment' or mismatching in maternal response (Beebe and Lachmann 1988): thus mothers of ambivalently attached children can be observed to force themselves on their children when they are playing happily, and ignore them when they are in distress.
Brazelton and Cramer (1991) propose a similar model in which they break down the components of secure mother-child interactive patterns into four main features: synchrony (temporal attunement), symmetry (matching of actions), contingency (mutual cueing), and 'entrainment' (the capturing of each other's responses into a sequence of mutual activity). On the basis of this, play, and later infant autonomy, begins to emerge. Insecure attachments result from intrusiveness or under-responsiveness. They have developed an experimental model of the latter in their 'still face' experiments in which the infant is momentarily presented with an unmoving image of the mother, who is prohibited from picking up the baby or responding to it. The baby shows disappointment, gaze aversion and self-soothing strategies, which match those seen in the children of clinically depressed mothers.
As we have seen in the previous chapter, aggression is a major component of the initial response to threatened separation. Both patterns of insecure attachment can perhaps be understood in terms of the interplay between the need for attachment and the aggressive response to the threat of separation. The ambivalently attached child shows overt aggression towards the inconsistent mother who, in the Strange Situation, has just 'abandoned' him for two successive periods (albeit only for 3 minutes - but how was the one-year-old to know that? ). It is as if he is saying, 'Don't you dare do that again! ', but clinging on at the same time since he knows from experience that she will. The avoidant child shows little overt aggression in the Strange Situation, although these children do show outbursts of unprovoked aggression at home. It may be that the avoidant response is a way of dampening aggression and so appeasing the mother to whom the child needs desperately to feel close, but whom he fears will rebuff him if he reveals his needs too openly, or shows her how angry he feels about being abandoned (Main and Weston 1982).
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The clock-watcher
A clinical example of avoidant attachment in adulthood is provided by a patient who, although faithfully reliable in her attendance at therapy, found it difficult to enter affectively into sessions which consisted mostly of a catalogue of the preceding week's events. She was meticulous about timekeeping, kept a close eye on her watch throughout the sessions, because, she said, she was terrified to overrun by a single second. As a solicitor she knew how annoying it was when clients outstayed their allotted time. The effect of this clock-watching was quite irritating to her therapist, who commented that timekeeping was his responsibility and tried to persuade her to remove her watch for sessions. It then emerged that her phantasy was that without her watch she would get 'lost' in the session, lose control of her feelings and at just that moment the therapist would announce that it was time to stop; she would then get so angry she would 'disgrace' herself, the therapist would not tolerate this and would break off the treatment. She had been a rather 'good' if distant child who had spent a lot of time on her own, while her older sister had been renowned for her tantrums and angry outbursts. By keeping her distance in a typically avoidantly-anxious pattern, she had maintained some sort of contact with her therapist (and presumably as a child, her parents), while avoiding the danger of threatening her tenuous attachments with her rage. She also kept some sort of coherence in the face of fear of disintegration. The price she paid for this adaptation was affective distancing, low self-esteem ('He would not tolerate me if he knew what I was really like') and the lack of a sense of movement and growth in her life.
THE STRANGE SITUATION AS A PREDICTOR OF SOCIAL ADJUSTMENT
The idea that anxious attachment patterns represent an adaptation or compromise to a sub-optimal environment is borne out by follow-up studies of children classified at one, and tested at pre- school, on school entry and again at ten (Bretherton 1985). At two years, securely attached children have a longer attention span, show more positive affect in free play, show more confidence in using tools, and are more likely to elicit their mother's help in
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difficult tasks compared with anxiously attached children. Their nursery teachers (blind to attachment status) rate them as more empathic and compliant and higher on positive affect. In peer interaction avoidants are hostile or distant, while ambivalents tend to be 'inept' and to show chronic low-level dependency on the teacher, and to be less able to engage in free play by themselves or with peers.
Evidence that the patterns of behaviour defined by the Strange Situation behaviour carry forward into subsequent development comes from the Grossmans (1991), who have shown that patterns of behaviour on re-union were 87 per cent predictable between one year and six years. They also showed that six-year-olds classified at one year as secure played concentratedly and for longer, were more socially skillful in handling conflict with their peers, and had more positive social perceptions, compared with children who had been rated as insecure as infants. Sroufe (1979) sees secure-rated children as having greater ego control and ego resiliency than those who were insecure. Secure children were rated by their teachers as neither overcontrolled nor undercontrolled, while avoidants were overcontrolled, ambivalents undercontrolled. Resiliency was inferred from such statements as 'curious and exploring', 'self-reliant, confident'. Stroufe concludes: 'What began as a competent caregiver-infant pair led to a flexible resourceful child. . . . Such predictability is not due to the inherently higher IQ of the securely attached infant, or, apparently, to inborn differences in temperament. '
LANGUAGE, NARRATIVE, COHERENCE
So far we have confined our account to attachment behaviour. As we look now at older children and their mothers, we turn to the trickier but psychotherapeutically more salient topics of the nature of attachment experience, its internal representation and how it manifests itself in language.
Main et al. (1985), Bretherton (1991b) and Cassidy (1988) have tried to tap into the child's experience of attachment by the use of play techniques such as a picture completion task, story completion, and puppet interview and story all depicting in different ways episodes of separation and re-union. Children tend to reveal their attachment histories through their play and imaginative activity. Avoidant children at six tend to draw figures
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with blank faces and no hands, suggesting a lack of responsiveness and holding in their lives. Secure children in response to a picture- story task give coherent, elaborated responses, including references to their own separation experiences, and are able to suggest positive ways in which separated figures could resolve their difficulties. Avoidant children, by contrast, describe separated children as sad, but cannot think of ways to help them. Secure children at six were more able to give a balanced view of themselves as good, but not perfect, while insecure children saw themselves as either faultless or bad. It should be noted that these results were much more consistent for the avoidant than the ambivalent group who gave very varied responses to the play tasks, without a clear pattern emerging. The disorganised group ('D') emerged more clearly in these as opposed to previous studies, showing bizarre or disorganized responses to picture- and story- completion tasks.
Main (1991) presents some remarkable preliminary findings of a follow-up study in which ten- and eleven-year-olds, who had been classified in the Strange Situation at one year, were asked for a spoken autobiography. There was a 75 per cent correspondence between classification at one and at ten. Compared with the insecurely attached, the secure children's stories were consistently more coherent, had greater access to memories, especially of their pre-school years, and showed more self-awareness and ability to focus in on their own thought processes, a phenomenon Main calls 'megacognitive monitoring' - the ability to think about thinking.
The findings so far, which represent more than a decade of 'post-Bowlbian' research into Attachment Theory, can be summarised as follows. Relationship patterns established in the first year of life continue to have a powerful influence on children's subsequent behaviour, social adjustment, self-concept and autobiographical capacity. These effects last for at least ten years. Mother-infant relationships characterised by secure holding (both physically and emotionally), responsiveness and attunement are associated with children who are themselves secure, can tolerate and overcome the pain of separation, and have the capacity for self-reflection.
These results undoubtedly support the view that the early years of life play a crucial part in character formation, and show in a fascinating way the continuity between the pre-verbal infant self
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and the social self as we commonly conceive it. But two important qualifications need to be noted. First, since the parent-child relationship operates continuously as development proceeds, what we are seeing is not so much the result of some irreversible early events as an ongoing relationship with its own 'epigenetic' stability. There is evidence that if a mother's circumstances change - for example, a single parent entering into a stable relationship with a partner - then attachment status for her child may change, in this case from insecure to secure. Similar changes can occur, as we shall see later in the chapter, when mother and infant are both treated with psychotherapy (Murray and Cooper 1992). Second, in presenting these findings the emphasis has been on the contribution of the parent, especially the mother, with the infant's role being relatively passive. Clearly this is a gross oversimplification, and temperamental, or even neurological, factors in the child will play their part in the relationship with the parent, and subsequent social adjustment. Attachment status is quite a crude classification and clearly there will be a spectrum of subtle characterological features within it. Nevertheless, the evidence seems to be that the parent is the determining factor and that a 'good' mother even with a 'difficult' baby will, by one year, be likely to have a securely rather than insecurely attached child. For example, the amount a child cries at one year seems to depend more on the mother than the child: there is a strong correlation between prompt and sensitive maternal responsiveness to infant crying in the first three months of life and reduced (as compared with children of less responsive mothers) crying at one year, whereas there is no correlation between the extent of infant crying itself in the first three months and the amount of crying at one year.
This leads us directly to the issue of the inter-generational transmission of attachment. If relationships are in some way internalised by the growing child as 'character', what happens when that child grows up and becomes a parent? We know from Harlow's (1958) experiments that infant monkeys separated from their mothers show, when they become sexually mature, gross abnormalities in mating and parenting behaviour. Can we trace in the infinitely more complex language- and experience-based world of the human primate, connections between a mother's capacity to provide secure attachment for her child, and her experiences with her own mother when she was a child?
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THE ADULT ATTACHMENT INTERVIEW
The Adult Attachment Interview (AAI) was devised by Main and her co-workers (1985) as a tool for assessing the working models or inner world of the parent with respect to attachment. It is a semi-structured interview conducted along the lines of a psychotherapy assessment aiming to 'surprise the unconscious' into self-revelation (Main 1991). The subject is asked to choose five adjectives which best describe the relationship with each parent during childhood, and to illustrate these with specific memories; to describe what she did when she was upset in childhood; to which parent she felt closer and why; whether she ever felt rejected or threatened by her parents; why she thinks her parents behaved as they did; how her relationship with her parents has changed over time; and how her early experiences may have affected her present functioning.
The interviews are audiotaped and then rated along eight scales: loving relationship with mother; loving relationship with father; role reversal with parents; quality of recall; anger with parents; idealisation of relationships; derogation of relationships; and coherence of narrative. The 'state of mind with respect to attachment' of the interviewees can then reliably be assigned to one of four categories: Autonomous-secure, Dismissing-detached, Preoccupied-entangled and Unresolved-disorganised.
The Autonomous-secure parents give accounts of secure childhoods, described in an open, coherent and internally consistent way. Attachments are valued, and even if their experiences have been negative there is a sense of pain felt and overcome. The Dismissing-detached group give brief, incomplete accounts, professing to having few childhood memories and tending to idealise the past with such remarks as 'I had a perfect childhood'. Preoccupied-entangled parents give inconsistent, rambling accounts in which they appear to be overinvolved with past conflicts and difficulties with which they are still struggling. The Unresolved-disorganised category is rated separately and refers specifically to traumatic events such as child abuse which have not been resolved emotionally.
Several independent studies have shown remarkably consistent correlations between the attachment status of infants in the Strange Situation, and that of their mothers in the AAI. A number of retrospective studies have shown a 70-80 per cent correspondence
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between infant security and parental attachment status on the AAI. Thus Main and Goldwyn (1984) found that 75 per cent of secure infants had mothers who were rated Secure-autonomous, while mothers of avoidant infants tended to be Dismissing- detached, and ambivalent infants had Preoccupied-entangled parents. The Grossmans found 77 per cent correspondence, and Ainsworth 80 per cent. Even more striking are the findings of Fonagy and his co-workers (Fonagy et al. 1991), who administered the AAI to prospective parents during pregnancy and found that the results predicted infant attachment status in the Strange Situation at one year with 70 per cent accuracy. Of insecure infants 73 per cent had insecure mothers, and only 20 per cent of secure infants had insecure mothers, while 80 per cent of secure mothers had secure infants. The influence of fathers appeared to be less: 82 per cent of secure fathers had secure infants, but 50 per cent of insecure fathers still had secure infants. This supports the view that attachment status is a function of the infant-parent relationship, rather than of temperament, and also suggests that maternal, rather than paternal, insecurity is the more potent transmitter of insecure attachment across the generations.
Prospective findings were less clear-cut for the preoccupied parent-ambivalent infant correlation. Many ambivalent children had mothers who were apparently secure when given the AAI in pregnancy. However, Fonagy et al. (1992), on reviewing these interviews, found evidence of a certain 'fragility' in the replies of these mothers, suggesting a tendency to idealisation which could easily be mistaken for security. There is some evidence that ambivalent children may have shown physiological immaturity at birth, or are the products of difficult labours, and it is possible that immaturity in the infant may have exposed the mother's 'fragility' in such a way as to produce an ambivalent attachment status at one year.
THEORETICAL INTERLUDE
The findings of this new generation of post-Bowlbian researchers are summarised in Table 6. 1 and produce a coherent picture of benign and vicious cycles of security and insecurity. Secure mothers are responsive and attuned to their babies and provide them with a secure base for exploration. They are able to hold them, delight in them, and cope with their discontent and aggression in a
Table 6. 1 The continuity of secure and insecure attachment
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satisfactory way. These mothers have a balanced view of their own childhoods which, even if unhappy, are appraised realistically. Their children, secure as infants, grow up to be well-adjusted socially and to have a realistic self-appraisal and a sense that separation, although often sad and painful, can be responded to positively. Secure mothers and secure children have a well- developed capacity for self-reflection and narrative ability, and convey a sense of coherence in their lives.
Insecure children, by contrast, especially if avoidant, tend to have mothers who found holding and physical contact difficult, who were unresponsive to their infant's needs and not well attuned to their rhythms. These mothers tended to be dismissing about their relationships with their parents and to be unable to tell a vivid or elaborated story of their own childhoods. As they grow up, avoidant children tend to be socially isolated, to show unprovoked outbursts of anger, to lack self-awareness and to be unable to tell a coherent story about themselves.
Are we seeing in these insecure children the roots of adult personality difficulty and neurosis? If so, what can we learn about the mental mechanisms that may underlie these disorders, and do they provide clues as to how psychotherapy might help to reverse them? We shall discuss in the next two chapters the parallels between avoidant strategies in infancy and some of the features of borderline personality disorder, and the possible links between phobic and dependency disorders in adults and patterns of ambivalent attachment in infancy. Our concern here is to try to conceptualise how maternal handling becomes internalised as infant psychology. In Fraiberg's (Fraiberg et al. 1975) telling metaphor: 'In every nursery there are ghosts. These are the visitors from the unremembered pasts of the parents; the uninvited guests at the christening. ' How do the parental ghosts get incorporated into the internal working models of the infant? Three inter-related ideas can be used to clarify this: avoidance of painful affect (Grossman and Grossman 1991), consistency and coherence of internal working models (Bretherton 1991a), and self-reflection (Fonagy 1991; Fonagy et al. 1991, 1992).
As we have seen in the previous chapter, Bowlby views the capacity to 'process' negative affect - to feel and resolve the pain of separation and loss - as a central mark of psychological health. Parents of insecure infants fail to respond appropriately to their infant's distress, either ignoring it (avoidants) or becoming over-
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involved, panicky and bogged down in it (ambivalents). It seems possible that because these parents have not been able to deal with or 'metabolise' (Bion 1978) their own distress they cannot cope with pain and anger in their infants and so the cycle is perpetuated. The infant is faced with parents who, due to their own internal conflicts or ego weakness, cannot hold (Winnicott 1971) the child's negative feelings of distress or fear of disintegration. The child is therefore forced to resort to primitive defense mechanisms in order to keep affects within manageable limits.
