Sunday, April 14, 2019

Remembering Sidney Blatt

Yesterday (April 13, 2019) the Tampa Bay Psychoanalytic Society’s own John Auerbach, PhD gave tribute to the late psychoanalyst Sidney Blatt. Blatt put forth some interesting ideas such as that of two developmental lines, relatedness and self-definition which were linked to two types of depression, anaclitic (Greek for leaning against) and introjective depression, respectively. Those with anaclitic seemed dependent on others to love them while those with introjective were self-critical and riddled with guilt. Rather than seeing these two developmental lines as sequential, one more mature than the other -- as Blatt and other traditional psychoanalysts had originally conceived -- Blatt came to understand that relatedness (once considered infantile and hysterical personalities) and self-definition (paranoid or obsessive personalities) develop in parallel, one co-defining the other, opposites only relative to each other. Auerbach noted that, of Erickson’s eight developmental stages, only two (Trust v. mistrust and Intimacy v. isolation) were about relatedness, while the rest were about self definition (autonomy, initiative, industry, generativity, etc).
The personality develops in is a continuous dialectic between relatedness and self definition. Deficits in or over emphasis of either developmental line leads to psychopathology. These polarities of relatedness and self definition were applied by Blatt et al to attachment theory and separation, respectively, where avoidant attachment presumably correlated with introjective depression, and such patients better utilize the couch, while ambivalent-resistant were tied to anaclitic depression, and may benefit more from face to face treatment. [Consider that one patient may, in different self states, exhibit both polarities. Blatt actually posited impairment was initially greater with mixed type in-patients (they also improved more). Perhaps this is because of greater dissociation at work?]
Blatt et al integrated mental representations with Bowlby’s concept of  internal working models to better explicate insecure attachments and developed a number of research tools. The Object Relations Inventory asks the patient to describe mother, father, significant other, self, and their therapist at different points in time over the treatment. This inventory apparently allowed clinicians to measure therapeutic change in patients in the [Austin]Riggs-Yale Project study by measuring changes in the developmental organization of their mental representations of self and other. Blatt et al also developed the Differentiation-Relatedness Scale to rank where a patient, at any time in the treatment process, stood in her/his capacity to be both separate and attached, based, in part, on reflective capacity.

Monday, April 8, 2019

Clinical Use of Attachment Theory

A gifted therapist whom I supervise serendipitously provided a clinical example illustrating the usefulness of Attachment Theory. The therapist had just begun treatment with a nineteen year old female patient who stated in their very first meeting, ‘I had four previous therapists and they all irritated me by asking questions. Don’t ask me questions, just give me a task and then observe what I do and give me information on what you observe.’ She added, “when people irritate me, I do something to irritate them back.’ For the therapist it felt there was an unmistakable need of the patient to be in control.
Controlling behavior in Attachment Theory brings to mind the observation in six year olds who had a history of disorganized attachment at one year, disorganized, perhaps, because their attachment figures were frightened or frightening. These six year old children exhibit controlling caregiving or controlling punitive behavior. What might have led to the above patient’s need to control the therapy situation? Had her parents been too controlling (frightening) or had they been unable to ‘take control’ [regulate] of the situation (frightened) causing the patient to prematurely need to ‘stepup’ and take things into her own hands?
Both, said the therapist: The parents had frightened the patient as a little girl by beating her, and they had failed to attend to her emotional life. The patient says there is nothing she wants except death, but the patient must kill others before she kills herself. The patient recognizes that either action (suicide or homicide) will serve to indict the parents. Perhaps it is her parents she will kill. The parents confirm that it is their daughter who is now in control for they tip toe around her so as not to set her off. [It has become a life-death struggle for a child to save herself when faced with a dangerous onslaught against her developing self and her developing agency.]
The patent predicts whether her day will turn out poorly or well based on whether the calendar date is odd or even. [I muse that OCD symptoms give a sense of control, control about the future.] The patient cannot sleep before an exam or a doctor’s appointment or a trip. [Perhaps she must remain vigilant to predict what is coming. Predicting a beating or what she needed to do next would be important to a small child whose parents are frightening and frightened.]

Sunday, March 24, 2019

Dependency is not the same thing as Attachment

Inexperienced therapists --- and some patients, too --- often worry that patients will become ”dependent” on the therapist and unable to, one day, leave therapy. This worry may be confusing dependency with attachment. Bowlby, according to Sable, distinguishes the two by their observable, distinct behaviors. For example, babies are dependent on others for food, but eventually grow to be able to feed themselves; and the other who provides the bottle may be substituted. Attachment needs, however, are life long and are not related to immaturity. The attachment bond/attachment figure is not so easily interchangeable. Development of attachment bonds is an achievement, not something to be outgrown.
Furthermore, Bowlby thought that fears [on the part of the therapist] about dependency could obfuscate awareness of the universal human need for attachment [in their patients]. Therapists provide an attachment bond and a secure base [through affect regulation/attunement, through timely and consistent repair of ruptures, and through shared affective experience- per Beebe and Lachmann; and through a ‘moving along’ toward a shared intention- per Boston Change Process Study Group; by being emotionally present and honest, yes, and by being punctual]. This secure base allows the patient to explore novel, and ‘safe surprises’ [Bromberg], such as previously disavowed affective states.
Just as with children viz a viz the caregiver, secure attachment develops in patients an increased psychological self sufficiency from which to explore their inner and outer worlds, and, in relationship with the therapist, reconfigures ‘internal working models’ [Bowlby] --- internal working models being a kind of ‘implicit relational knowing’ [Lyons-Ruth] or relational paradigm [Herzog] encoded in the brain as a pattern of behavior or way of ‘being with’ another. While it may take years in the treatment for a secure attachment to develop, the existence of this secure attachment decreases, not increases, dependency. (Is it counterintuitive to learn that increased secure attachment decreases dependency?) The therapist, through self reflection and supervision, and through being attuned to patients’ needs, comes to terms with discomfort regarding being depended upon and being intimately, authentically related to the other.

Sable, P. (1994). Anxious Attachment in Adulthood: Therapeutic Implications. Psychoanal. Soc. Work, 2(1):5-24.

Tuesday, March 19, 2019

Relational Ideas and Attachment

Wallin explicates the dovetailing of Attachment Theory with relational and intersubjective clinical practice. For example, repair of ruptures and negotiation of differences are important both in the clinical situation and in building secure attachment. Development of a healthy, flexible, broadly experiencing, authentic self is an aim of treatment and of the loving caregiver toward the infant.  Relational therapy -- by therapists examining their own participation and influence, and by inviting the patient to aid the therapist’s self reflection-- recognizes the capacities of the adult patient.
Wallin highlights for us some of the important ideas in relational therapies:  Influence in relationship is mutual and reciprocal, though roles may be asymmetric, as with therapist-patient or parent-child. Thus, transference is co-created. Resistance, too, is co-created, and a communication to the therapist that some experiences remain too painful as yet for the patient, reminding the therapist to be more attuned. It is impossible, sometimes even harmful to attempt, to be neutral, abstinent, and anonymous. Mindful of the patient’s best interest, self disclosure can instead be useful, for -- just as it is important for a child to know the mind of the caregiver in order for the child to develop a mind of one’s own -- it is useful for a therapist to feel and contain affective experiences if the patient is to do so as well.
Self disclosure, knowing the mind of one’s therapist, can foster mentaization. Speaking to our affective experience viz a viz the patient experientially communicates to the patient that dissociated thoughts and feelings can be safely owned, discussed, integrated. It can let the patient know of her/his effect on the therapist, bulwarking agency. It can model the link between words, feelings, experience. It can be a step towards finding our way out of enactments.
Enactments are an opportunity to access dissociated experiences. Self states which are rejected by the caregiver tend to be dissociated by the child. Integrating dissociated experiences -- by welcoming in, containing, speaking to our own experience, etc -- are all part of relational therapy and allow the patient to experience the therapist as a new attachment figure.
Wallin, D.J. (2007) Attachment in Psychotherapy Chapter 10. Deepening the Clinical Dimension of AttachmentTheory. (Guilford Press, NY)

Saturday, March 16, 2019

Sufi Poem

This being human is a guest house. Every morning a new arrival.
A joy, a depression, a meanness ,some momentary awareness comes as an unexpected visitor.
Welcome and entertain them all! Even if they are a crowd of sorrows, who violently sweep your house empty of its furniture, still, treat each guest honorably. He may be clearing you out for some new delight.
The dark thought, the shame, the malice, meet them at the door laughing and invite them in.
Be grateful for whatever comes, because each has been sent as a guide from beyond.
-- Jelaluddin Rumi (1207-1273)
Trans: Coleman Barks

-- submitted by David Baker, Ph.D.

Tuesday, March 12, 2019

Attachment and Development of the Self

The TBIPS’ Attachment and Affect second year course continues to utilize David Wallin’s very readable and informative 2007 book Attachment in Psychotherapy. In Chapter 7. How Attachment Relationships Shape the Self, Wallin connects the child’s developing sense of self and agency with the caregiver’s capacity to participate in what Lyons-Ruth (1999) termed ‘collaborative communication,’ with its four main components of 1) being receptive to the child’s affects and experience; 2) initiating timely repair of inevitable failures in collaborative communication; 3) providing “scaffolding” [Kohut] to the child’s emerging capabilities; and 4) staying engaged [and/while struggling] with the child even across differences in experience and agendas. [Recall Beebe’s and Lachmann’s (1996) three principles of salience: ongoing affect regulation; timely and consistent repair of ruptures; shared heightened affective moments--providing both security and safe novelty]. It goes without saying that all four elements also serve the therapist and client well.

Being inclusive and open to the “entire array of affective communications” (Lyons-Ruth) of the child’s experience helps the child integrate its feelings, thoughts, and behaviors [unlike, for example, a dismissing parent who implicitly teaches the child that certain feelings or behaviors are unwelcome and thus to be dissociated as ‘not-me’ (Bromberg)]. Lyons-Ruth says a collaborative caregiver actively structures dialogue to elicit the child’s needs and desires. Consistent and timely repair implicitly shapes a child’s expectations about caregivers and the world [Recall Erikson’s first stage Trust v. Mistrust]. Scaffolding supports the child’s emerging sense of self and agency so that the child can safely explore, have experience of self confidence as well as experience that the self’s agency does not jeopardize the relationship. Staying engaged [e.g. surviving, ala Winnicott] fosters the experience of intersubjectivity, allowing for connection even within difference.

Parents of securely attached infants mirror and ‘mark’ [Gergely and Watson, 1996] vocalizations, affect, and facial expressions with midrange [Beebe and Lachmann, 1997] contingency, while low range contingency may predict avoidant and highest range contingency disorganized attachments.  Secure parents, flexibly respond to a child’s needs both for attachment and proximity and for autonomy and exploration. Their communication is collaborative, contingent and affectively attuned. Note that, like Main, Lyons-Ruth (1999) speaks to the coherence of dialogue, using Grice’s criteria for communication: quantity (e.g. succinct while complete), quality (truthfulness and internal consistency), relation and manner (collaborating with listener; relevant). The therapist’s responsiveness also enhances the client’s sense of having effect on the other, enhances agency.

Wallin notes that some (dismissing) patients -- obsessive, narcissistic, schizoid-- may have learned as children (avoidant attachment) to distance themselves from others and to rely on left-brain strategies. Their dismissing parents may have discouraged attachment behaviors. Conversely, hysterical and borderline individuals may hyperactively seek closeness, preoccupied with others, by maximizing emotional distress (ambivalent-resistant attachment as children). Their preoccupied parents may have discouraged autonomy. Unresolved adults, who as children had disorganized attachment without a consistent pattern of coping behaviors, may oscillate between distancing (“avoidance of closeness”) and preoccupation (“terror of abandonment”) and with dissociated affects.

Wallin, D.J. (2007) Attachment in Psychotherapy Chapter 7. How Attachment Relationships Shape the Self. (Guilford Press, NY)
Lyons-Ruth, K. (1999). The Two-Person Unconscious. Psychoanal. Inq., 19(4):576-617

Sunday, March 10, 2019

Neurobiology of Emotions

Panksepp describes seven, primary process* emotional networks [here primary process refers to basic, evolutionarily determined systems located in deep subcortical brain structures, not to types of thinking] which can be elicited by electrical stimulation to various brain centers; they are Seeking, Rage, Fear, Lust, Care, Panic, and Play. They are evolutionarily determined  --- not from the later evolved cortex --- but from subcortical structures such as the amygdala and from brainstem and vagus, and thus are found in other species. The four pleasurable emotional networks are Seeking, Lust, Care, and Play; Rage, Fear, and Panic are not pleasurable, that is, animals in laboratory experiments will not repeatedly push levers to stimulate these networks.

Seeking, such as looking for food or exploring the world [for the pleasure of exploration] informs motivation and ‘drives’. Rats will repeatedly push levers to stimulate pleasure centers in their brains and then subsequently energetically explore their surroundings. Frustration and anger may be brought on by thwarting Seeking behaviors. [This motivational and arousal system is found in the nucleus accumbens, ventral tegmental area (VTA), the lateral hypothalamus, and periaqueductal gray area (PGA) with diffuse mesocortical and mesolimbic pathways, the latter, particularly dopamine pathways of the brain responsible for cravings and addictions.]

Rage can be elicited in predatory animals by stimulating specific parts of the brain [an attack system; the medial amygdala to bed nucleus of stria terminalis (BNST) to anterior and ventromedial and perifornical hypothalamus to dorsal PAG.] When aggression is predatory --from the Seeking system-- animals will self stimulate by pushing levers, but when it is agitated anger, it is not pleasurable for them and they will not push the lever. This indicates two types of aggression.

Fear of attack by a predator is not the same as fear of separation (panic). [Central and lateral amygdala to medial hypothalamus to dorsal PAG to nucleus reticularis pontine caudalis.] Fear is meant to alert us to dangers, and elicits, via the autonomic nervous system’s sympathetic and parasympathetic circuitry, flight or freeze reactions. This system promotes generalized anxiety, some phobias, and PTSD.

Panic results from separation from the attachment figure. It is different from Fear. The soothing and comfort found with the good enough attachment figure mimics that of opioid receptor stimulation. [Powerful attachment to exogenous opioids is known as addiction.] Oxytocin  -- the attachment [bonding] hormone-- also soothes separation panic. Prolactin,as well, affects attachment. [anterior cingulate/anterior thalamus to BNST/ventral septal to midline and dorsomedial thalamus to dorsal preoptic hypothalmic to dorsal PAG. Panic vocalizations found in certain animals (such as dogs, guinea pigs) originate in the periaqueductal gray area of the brain and the medial thalamus and basal ganglia.] Panksepp posits that depression may be a mechanism to conserve energy by terminating separation distress.

Lust motivates sexual behavior and ensures the survival of the species. [Paraphrasing TS Elliot: Birth, copulation and death are all the facts when you get down to brass tacks.] Freud, in his libido theory, overvalued it as one of the two most important drives. Humans’ cortical centers can override these biological imperatives according to cultural mandates but other animals cannot. [BNST to corticomedial amygdala to preoptic and ventromedial hypothalamus to lateral ventral PAG]

Maternal Care nurtures offspring ensuring the survival of the species. Without it, most mammalian offspring could not survive. As with all the systems, there is variability in its intensity with strength of devotion to the offspring dependent on the mother’s own capacities and resilience. Maternal care and bonding is heightened by oxytocin. It also plays a part in romantic attachment. [Anterior cingulate to BNST to preoptic hypothalamus to VTA to ventral PAG]

Play elicits joy. It is pleasurable and allows for healthy engagement with others. It forges bonds and is the antidote to the pain of separation. Conversely, psychic pain inhibits play. Panksepp even tickled rats and made them chirp (laugh). Rats deprived of social interaction became play hungry (just like those deprived of food would be hungry for food). Decerebrate rats still played! Play in young animals helps them become more socially --and sexually-- competent (in the cortex) adults. Deprived of play, animals may become aggressive. [Human children need time for play, too. Panksepp wonders if overdiagnosis of ADHD comes from play hunger; If there is deprivation of lower brain needs, the upper cortex function is ‘distracted.’]

Traditional psychoanalysis with its emphasis on left brain language centers (narrative, interpretation, insight) of the cortex may nonetheless trickle down to deeper brain structures.
Emotional regulation experienced in the therapeutic context may effect change at subcortical levels and in neuronal networks at the level of dendritic branchings as well as ‘priming’ the soothing and ‘feel good’ neurotransmitters (oxytocin, opioids, dopamine).

*Panksepp refers to secondary process as learning in the basal ganglia to link emotions and perceptions, and tertiary process as learning from experiences in the neocortex which engenders thinking. Ancient feeling states forge memory and knowledge.

Davis, K; Panksepp, J (2018) The Emotional Foundations of Personality: A Neurobiological and Evolutionary Approach.

Tuesday, March 5, 2019

Attachment and representational models

Reminiscent of object representations of self and others from Object Relations theory and, later, Stern’s RIGS (representations internalized and generalized), Bowlby described three aspects of Attachment Theory: “Internal Working Models,” attachment behaviors (crying, clinging, proximity, etc) and ‘defensive exclusion’ [denial, dissociation, etc]. Bowlby recognized that the environment (i.e. relationships) influenced development and that healthy attachments helped a child weather stressful life events. What is to be emphasized is it is the relationship with its implicit relational knowing that is ‘internalized’ (encoded in the brain). Because it is the relationship (not simply the ‘object representation’) which is encoded, either pole [or both] of that relationship (e.g. victim- rescuer; doer-done to, etc) is accessible to be enacted.  

While Object Relations theory writes about unstable representations of self or other, it might sometimes be better conceived to think in terms of self states, or multiple selves, each state with its ‘stable’ [rigid] adherence to a particular way of being with a particular attachment figure, also called implicit relational knowledge. ‘Instability’ or switching of self states, with other states moving to the background or dissociated, including its concomitant affective dysregulation, is the hallmark of [relational] trauma, often attributed to personality disorders with ‘borderline’ organization. [Because incoherence in narrative -- see Adult Attachment Interview--, lability of affect, denial and dissociation all make a person look ‘borderline psychotic’].

What research now reveals is that insecure attachment, especially later preoccupied and/or unresolved, is predominant in Borderline Personality Disorder (BPD), and that emotional violence/neglect are more strongly correlated with development of BPD than even the trauma of sexual abuse.

Buchheim, A. and K├Ąchele, H. (2003). Adult Attachment Interview and Psychoanalytic Perspective. Psychoanal. Inq., 23(1):81-101

Wednesday, February 27, 2019

Polarities, Attachment and Personality Development

Blatt's & Levy's paper provides a broad theoretical matrix concerning the contribution of attachment theory, psychoanalysis and developmental research to personality development, as well as provides a basis for the conceptualization of psychopathology. They also elaborate a fuller developmental perspective in understanding the insecure attachment patterns as they pertain to the psychoanalytic view of mental representations and to Bowlby’s Internal Working Models. Additionally, the authors focus on integrating the multiple polarities that exist in attachment patterns, especially that of separation [autonomy] (avoidant attachment and introjective processes)  vs. attachment [connection/relationship] (preoccupied and interpersonal processes), and internal workings models (cognitive vs. developmental), mental representations and psychoanalysis (drives - object-representations).

Specifically, a clinical and research overview is given to demonstrate the polarity concerning the development of personality. Blatt et al suggest as fundamental dimensions in personality development  relatedness and self-sufficiency; Freud (1930) the urge toward happiness (egoistic) and the urge toward union (altruistic); Loewald (1962) separation and union; Balint (1959) connectedness (ocnophilic tendency) and self-sufficiency (philobatic tendency), Shor and Sanville (1978) intimacy and autonomy; Adler (1951) discussed the balance between social interest and self-perfection; Rank (1929) both self-and-other-directedness; while Horney (1945,1950) defined personality organization as either moving toward, moving against or away from interpersonal contact.  Other non-psychoanalytic personality theorists such as Angyal (1941,1951) discussed surrender and autonomy as two basic personality dispositions. Similarly,  Angyal, Bacan (1966) defined communion and agency; McAdams (1980,1985) and others described themes of intimacy and themes of power; Wiggins (1991), agency and communion. Spiegel & Spiegel (1978) noted two basic forces in nature- fusion and fission, integration and differentiation. Most theorists consider relatedness and self-definition as two independent processes, while others consider them as antagonistic or contradictory forces.

The authors -- in accordance with Erikson's epigenetic model of psychosocial development -- propose a dialectic, synergistic interaction between self and others and conceptualized personality development as involving two fundamental parallel developmental lines, the anaclitic or relatedness line and the introjective or self-definitional line. Based on these two lines, they define two distinctly different configurations of psychopathology. The first are the anaclitic psychopathologies which  primarily use avoidant defences and involve preoccupation with interpersonal relations, and the second, the introjective pathologies, are primarily concerned with establishing and maintaining a viable sense of self and tend to use counteractive defences.
Several studies have shown that anxious-resistant attachment is associated with an anaclitic/dependent type of depression, while avoidant attachment with an introjective/self-critical type of depression.

[Accordingly, the authors describe two subtypes of Avoidant attachment: the dismissive avoidant and the fearful avoidant, with the latter having more differentiated, complex mental representations and thus are considered to be developmentally more mature; and two types of Ambivalent-resistant: the compulsive care-seeking and the compulsive care-giving.] The disorganized style of attachment is based on Hesse & Main's research. They associated this type with the parental unresolved fear, defining two types of children's behavioral responses: the controlling punitive and the controlling-caregiving.  Lyons-Ruth also distinguishes two subtypes of Disorganized attachment resulting from two types of parental behavior: Disorganized Approach have mothers who are helpless-withdrawn [frightened], and Disorganized Avoidant have negative-intrusive hostile [frightening] mothers. There was a history of early trauma in these mothers, physical abuse or witnessing violence in D-Avoid mothers, and sexual abuse or parental loss in D-Approach mothers.

Lastly, Blatt and colleagues -- incorporating psychoanalytic theory, the cognitive developmental perspective of Piaget and Werner, and cognitive-affective components of mental representations for the self and other -- developed scales (The Early Memories Test, the Objects Representation Scale for Dreams, and others) for assessing the development and impairment of self and object representations. Their main goal was to examine the content and structure of mental representations (internal working models) in different types of attachment patterns, concluding that different developmental levels can be identified in the representations of individuals within each type of insecure attachment which offer explanations about the relationship of attachment classifications to various types of psychopathology.

-Ageliki Tsikli, Candidate, TBIPS

Blatt, S.J. and Levy, K.N. (2003). Attachment Theory, Psychoanalysis, Personality Development, and Psychopathology. Psychoanal. Inq., 23(1):102-150

Tuesday, February 26, 2019

Utilizing Attachment Theory with Adult Patients: Disorganized-Unresolved

Toddlers classified by the Strange Situation [Ainsworth] as having a disorganized attachment pattern [Main] usually had caregivers classified as unresolved on the Adult Attachment Interview [Main]. The unresolved caregiver can appear to the infant frightened or frightening, with dissociation as a hallmark of their own unresolved trauma. The trauma may be event trauma (war, separation, abuse) or relational trauma (chronic misattuenement, humiliation, or emotional abandonment). Persons with PTSD, dissociative disorders, and personality disorders with dysregulation of affect all could suffer from unresolved traumas.

Trauma unresolved can be ‘frozen’ in time and unpredictably experienced as if occurring in the present moment. It causes discontinuities in memory because overwhelming affect at the time of the trauma caused the amygdala to ramp up emotional, sensory, procedural memory storage but decreased the activity of the hippocampus, vitiating the hippocampus’ ability to give context and language (event memory) to the trauma. Without words and context the trauma remains inaccessible in the treatment situation except through its procedural and affective expression via enactments between the patient and the therapist.

The treatment situation offers a safe, reliable, intersubjective (i.e. respecting the agency of both participants) context -- different from experience with early, unreliable caregivers -- in which ruptures can be repaired and trauma can eventually be resolved. Mentalization, a necessary step away from psychic equivalence and on the road to developing intersubjectivity, is fostered by sharing -- always with the aim to protect the patient from shame, injury, intrusion -- the contents of the therapist’s mind.

Wallin, D.J. (2007) Attachment in Psychotherapy Chapter 14. (Guilford Press, NY)