Sunday, December 8, 2019

The Neurobiology of 'Stuckness' by Steven Graham, PhD

What Happened to Me When I Was Little?
The Neurobiology of "Stuckness"
Psychoanalysis has at times been referred to as the “forbidden journey” because it takes us places we (and our early caregivers) would rather not see or feel or remember. Psychoanalytic treatment is not for the timid. It takes courage even to attempt it. We can look at such work as an expedition or an adventure, and know we will not be alone as we walk through it. In fact, it is impossible to make such a trip successfully alone. The quality of the journey requires a trusted and competent and caring other. More on that in the next installment.

Most of us dare to risk the venture because we find ourselves stuck: in a depression, with anxiety, with a sense of negativity or meaninglessness, in a painful relationship, in a dead-end job, or with thoughts, memories, or feelings that intrude upon us unbidden. Dr. Allan Schore is a psychologist, psychoanalyst, and researcher whose work has attempted to integrate neurobiology, attachment theory, and trauma research with psychoanalysis and psychotherapy. He is the author of numerous articles and books (listed below), along with many YouTube videos in which he explains why people get stuck and how we can become unstuck. In addition to introducing you to this outstanding clinician and researcher, I also want to highlight a few of his insights that might prove meaningful to you. One of the important but often unasked questions I discover in my work with others is this: So, what happened to me when I was little? Schore’s insights help us begin to answer this all-important question.

The First Thousand Days is Crucial
When we add the nine months of in-utero development together with the first two years of the baby’s post-natal life, we are exploring these first 1000 days when the infant’s brain, particularly the right-brain, is expanding at a phenomenal rate. Schore’s research shows that it is the right hemisphere of the brain that is largely responsible for affect regulation (or emotional and body-based regulation) while the left brain (which develops more rapidly in the infant’s third year of life) is responsible for logic, language, and linear thought. 

Contrary to those who believe that infants are oblivious to the world around them, they are soaking it up. This is the pre-verbal stage when communication is primarily body-to-body and right-brain to right-brain. This is when children learn how it feels to be a human being, if and how they are special, loved, or worthy, what to expect from relationships, and whether their world is secure or insecure.

Later Emotional and Psychological Struggles Usually Begin During the First Thousand Days

I have heard people express with confidence how “resilient” babies are, that they can endure absent, depressed, misattuned, preoccupied, or chaotic caregivers and families during this first 1000 days and turn out to be just fine. The research proves just the opposite. It is during these early months and years of a child’s life that they are most vulnerable. We have all seen how important it is to support the back of the baby’s head and neck when holding them because they are so young and fragile. If we must take extra care with the child’s head, we must do even more so with the child’s mind.

Emotional Regulation is Crucial 

One of the most important gifts we bring to the child’s life is affect regulation, the ability to regulate the self during times of stress. Anyone who has been around a baby for any time at all knows one truth: the baby does NOT know how to self-regulate. It is up to the caregiver(s) to do this. These three processes are essential: soothing, vitalizing, and repairing.

#1. Soothing. When negative feelings (both emotional and physical) overwhelm the child, the caregiver must soothe. This requires the caregiver to show empathy, but also confidence that the distressing state is bearable and will pass. Perhaps rocking, singing, holding, feeding, or changing the diaper will eventually return the baby to a peaceful state. Over time, the baby will eventually develop the capacity to tolerate increasingly negative states of distress.

#2. Vitalizing. When babies smile or coo or want to play, it is up to the caregiver to expand this capacity as well. And so we play peak-a-boo, “this little piggie,” and other games with the baby. This will equip the developing child to experience the upper limits of the emotional range and learn to regulate it as well.

#3. Repairing. Unfortunately, caregivers cannot attune perfectly with their babies all the time. When we do misunderstand, we take responsibility: “Oh, I’m sorry. I thought you just wanted to be held, but I guess you are hungry. Let’s take care of that right now.” When we as caregivers learn to repair these misattunements, we help our babies trust that problems can be solved, especially the interpersonal ones. They also internalize the ability to show empathy toward others, which offers them a rich life in so many ways.

The degree to which a child has learned affect regulation may very well dictate that child’s future psychological well-being. 

Intergenerational Transmission of Trauma is Real 

Most of us as parents want to do everything we can to protect our children from any of the trauma. But what if we have not worked through our own trauma? While many whom I see in therapy easily recall painful interactions with their caregivers, others cannot remember anything out of the ordinary in their relationships with their parents at all, but then begin to tell stories about the significant trauma that their parents lived through. When we experience trauma, we may learn to dissociate, or disconnect, part of ourselves from the horrors around us in order to survive emotionally. This becomes part of our psychological way of being in the world. When caregivers who have been traumatized themselves (perhaps as children) hold their babies, they may at times dissociate, and the child’s sensitive right brain notices that mom or dad is not all there. Most often, the parent has absolutely no idea this is happening. This may also occur if the caregiver is depressed or anxious or distracted. Right-brain to right-brain, the baby is taking it all in: the sense of dread, profound sadness, overwhelming responsibility, inability to stay focused. The newborn has, of course, no words for these feelings: they live in the child’s nonverbal brain centers and often in the child’s body.

Repairing Such Damage from Childhood is Very Possible!

It is likely as we are reading these research findings that we are asking two essential questions: 1) what have I done to my children? and, 2) what happened to me? What I tell most parents I see in therapy is that it is not a matter of “if” they have wounded their children, but “how” they have done so … because we all have. One of the greatest gifts a parent of an adult child can give is the offer of repair: to recognize mistakes that were made, own them, ask for forgiveness, and attempt to restore the damaged trust to the extent that we can. The truth is that when we are parenting, we simply cannot see or know everything: this is part of the painful existential truth with which we all live. We are finite and limited, and it causes pain to ourselves and to our precious children.

The good news is that these brains of ours (and our children) are “plastic,” meaning they continue to change over time. And they can change toward health despite the trauma or neglect we may have received in our childhoods. Even though patterns were deeply established in our infancies, the first 1000 days of our lives, we have something that we did not have as infants: an intact brain which includes a fully operational left hemisphere along with the prefrontal cortex which does our thinking and planning for us. In essence, this means we can choose, in effect, to be re-parented. I will explain this in the next installment, coming out next week.

Selected Articles:
Schore, A.N. (1991). Early Superego Development: The Emergence of Shame and Narcissistic Affect Regulation in the Practicing Period. Psychoanal. Contemp. Thought, 14(2):187-250.
Schore, A.N. (1997). A Century After Freud’s Project: Is A Rapprochement Between Psychoanalysis And Neurobiology At Hand? J. Amer. Psychoanal. Assn., 45:807-840.
Schore, A.N. (2001). Minds in the Making: Attachment, the Self-Organizing Brain, and Developmentally-Oriented Psychoanalytic Psychotherapy. Brit. J. Psychother., 17(3):299-328.
Shore, A.N. (2002). Advances in Neuropsychoanalysis, Attachment Theory, and Trauma Research: Implications for Self Psychology. Psychoanal. Inq., 22(3):433-484.
Schore, A.N. (2011). The Right Brain Implicit Self Lies at the Core of Psychoanalysis. Psychoanal. Dial., 21(1):75-100.

Selected Books:
Schore, A. (1994). Affect Regulation and the Origin of the Self. Mahway, NJ: Lawrence Erlbaum Associates
Schore, A. (2003a). Affect Regulation and Disorders of the Self. Ed., New York: W.W. Norton & Company
Schore, A. (2003b). Affect Regulation and the Repair of the Self. Ed., New York: W.W. Norton & Company
Schore, A. (2019). Right Brain Psychotherapy. New York: W.W. Norton & Company
Schore, A. (2012). The Science of the Art of Psychotherapy. New York: W.W. Norton & Company
Schore, A. (2019). The Development of the Unconscious Mind. New York: W.W. Norton & Company. 

by Steven Graham, PhD

Monday, October 21, 2019

Attachment theory and clinical work

A ready advocate for the importance of understanding attachment in the clinical situation, I quote from Wallin’s (2007) Attachment in Psychotherapy
For patients whose healthy development was derailed by the shortcomings of … formative relationships, psychotherapy may recreate an interactive matrix of attachment in which the self can potentially be healed.
...attachment research enhances our ability as therapists to generate a developmentally facilitative relationship with our patients in which we are at once reworking old experiences and co-creating new ones.
Because many of our foundational experiences occur pre-verbally and became ‘internal working models’ (Bowlby), ‘representations of interactions that have been generalized’/RIGs (Stern), or ‘implicit relational knowing’ (Lyons-Ruth), Wallin suggests that therapists aid patients in integrating implicit bodily, emotional, and procedurally enacted experience [sometimes called ‘non-conscious’ to distinguish from the dynamic unconscious] - as well as symbolic, explicit experience - by attuning to these bodily, emotional, and enacted experiences of, and with, our patients as well as to the verbal and other symbolic experience. 

Wednesday, October 16, 2019

Foreign Climes

I recently had the privilege of guest teaching a clinical case course, this time to fourth year students, at a psychoanalytic training program separate from my home at the Tampa Bay Institute for Psychoanalytic Studies (a relational institute with an emphasis on trauma and attachment). Surprisingly, while these students had heard of attachment -- one had even translated the BCPSG’s Change in Psychotherapy into a foreign language, they seemed to have very little interest in it. The presenter went so far as to say any talk about attachment was mere theory (metapsychology) and did not have a place in psychoanalysis where “making the unconscious conscious” was the aim of treatment. Deepening treatment meant diving into the unconscious.  (Had this other institute not yet embraced the paradigm shifts in psychoanalysis from left brain narrative/interpretation/insight to co-created right brain implicit/procedural/often nonverbal communication?) 
I was reminded of the BCPSG’s ideas that 1. experiences do not always need to be verbalized for changes in implicit relational knowing to take place, and 2. that relationship may be foundational, while conflict (the contents of the Freudian dynamic unconscious) comes secondarily out of experience in relationships (as evident in attachment patterns observed at 12 months of age in the Strange Situation). In particular, I recalled Stern’s idea that a verbal/conscious search for meaning may sometimes actually impede the deepening of experience. Had the centrality of relationship in treatment eluded the curriculum of this strange (to me) institute? I will note that, when having taught clinical case seminars to its first and second year classes, the students seemed more interested, even excited by, ideas less well known to them.
The presenter in this fourth year seminar, on the other hand, eschewed attachment research and was certain that it was the patient’s responsibility, and hers alone, (in a blaming sort of way) to choose her own life, regardless of the patient’s early experiences and regardless of the present moment and the therapeutic relationship. The analyst was to make interpretations in order to bring unconscious motivations to consciousness. The class, upon hearing the case, could observe that the patient had been deprived of both a nurturing mother and of being allowed the opportunity for identificatory love with her father, yet the class saw no place for the therapist to provide a new attachment relationship where unfinished developmental business could safely be revisited. The therapist was decidedly uncomfortable with the idea of being either for the patient. The class mostly interpreted the rocky relationship between therapist and patient as the patient’s bent toward “competitiveness” (e.g. when the patient wanted to read a book the therapist mentioned) and thought it odd that I might, in addition, see the patient’s wish to identify with, be like the therapist. (And, of course, the rocky relationship between me and the class is a parallel process which humbles me.)

Friday, October 11, 2019

When the Analyst is Sexually Aroused

Continuing with the presentation to the Tampa Bay Psychoanalytic Society by Janine de Peyer on October 5, 2019, the afternoon session was about the analyst’s sexual arousal in the therapeutic session, a rarely discussed topic among mental health professionals. The ‘erotic transference’ is commonly discussed, but not ‘erotic countertransference.’ The analyst’s anger, fear, and love all seem more mentionable; we strive to refrain from being inappropriate, seductive or exploitative with our patients. Because the therapist must not act on her sexual desire, what becomes of this natural human response? Does one disclose it to the patient (Davies) despite a cultural prohibition to do so?  What about the dangers? 
[So many questions...] Can one ‘neutralize’ her erotic attraction without becoming overly constricted? Is the maternal countertransference safer, particularly when the erotic may connote the female sterotype of submission? Is the analyst comfortable being the object of desire? Was there trauma associated with this in the analyst’s own history? (The aging female analyst, unlike her male counterpart, must grapple with becoming less and less likely to be an erotic object for the patient.) Is there a co-created avoidance of the erotic transference? Also, the analyst might consider whether she is the one in the room holding the erotic feelings for a patient who has dissociated them. Sometimes for the patient, too, the maternal transference seems safer. Perhaps the patient needs to fend off hostility, impotence or felt power. In what ways might the analyst be inhibiting the patient’s erotic transference? Can the analyst be open to self states without causing trauma? Does the analyst want the patient to titillate her? 
Some of the countertransferential behaviors noted by de Peyer when attracted to a patient included presenting one’s best self (wardrobe, posture), and feeling resentful or betrayed when the patient recounts sexual encounters. 
Holding longing in contempt, desire may mean weakness. [This author sees the erotic transference/countertransference as an opportunity for mourning the loss of what one cannot have.] One attendee noted that, were the erotic feelings in the clinical situation to remain unmentioned, they might be acted out in life outside the therapy. [I might then, ala Lewis Aron, place the dilemma of the erotic countertransference on the table letting the patient know, for example, that while I share his joy I worry I might have had undue influence.] When there is shame surrounding erotic feelings, the other may have to hold the shame. de Peyer notes that perhaps the greatest gift an analyst can give her patient is her own shame. [owning it].
Davies, J.M. (1994). Love in the Afternoon: A Relational Reconsideration of Desire and Dread in the Countertransference. Psychoanal. Dial., 4(2):153-170. […]

Sunday, October 6, 2019

A Most Provocative Presentation

On Saturday, October 5, 2019, The Tampa Bay Psychoanalytic Society hosted Janine de Peyer. She elaborated three heretofore very neglected ‘countertransference’ positions. They were: when the analyst has a seemingly telepathic connection with a patient; when the analyst fears the patient; and when the analyst is erotically attracted to her patient.
Regarding ‘telepathy’: Evoking ideas from quantum physics, to quote from her 2016 paper, de Peyer says,
If particles in the quantum world communicate instantaneously with one another, jumping from one place to another without seeming to need to travel in between, would it not follow that patients’ and therapists’ minds would be capable of doing the same thing?
Is a mind a closed entity just as the brain encased in a skull? Or is the mind like particles in the universe with a connection and interconnection across time and space? When a person knows what another person is thinking, the exact word(s) -- even if the words were previously unknown -- how does one know? Is there a collective unconscious? a hive mind? Or can uncanny parallel thoughts, dreams, and actions between patient and analyst be explained by implicit relational knowing? [Implicit relational knowing not only relies on experience with the physical presence of another, perceiving microexpressions, changes in breath or smell, but these experiences are encoded in the brain to provide expectations on how to behave, even in novel situations (a ‘transference’)] And don’t mirror neurons also rely on physical presence and proximity? What about influence beyond sensory perception? How does one know of the death of a loved one thousands of miles away at the exact moment it occurs? And if humans are capable of knowing the thoughts of others across space and time, could our minds be bombarded with excess stimuli were we not to ignore this capability? Would all privacy of thought then be lost?
There was also a very interesting discussion about fearing from patients for our physical safety. Some thought the patient was trying to instill fear in the analyst. I, without attributing any malintent, prefer to think that a patient must show their own fear to the analyst, presenting it on a silver platter, when s/he evokes it in the therapist. Called an enactment, the analyst and patient together must play out the dissociated parts of the patient if the patient’s experience is to be known. The analyst, too, dissociates, of course, often out of shame (de Peyer noted that with a sexually aggressive male patient she had joined him in repudiation of the feminine by having equated ‘feminine’ with ‘victim’).  She had also dissociated her own aggression, leaving the patient to carry it, and carry it alone. Correspondingly, the patient had dissociated his own vulnerability; its recognition and ownership required by him in order to heal. 
Perhaps the most provocative (taboo) discussion came when talking about the sexual arousal of the analyst by the patient. [But I will leave that to the next post.]
de Peyer, J. (2002). Private Terrors: Sexualized Aggression and a Psychoanalyst's Fear of Her Patient. Psychoanal. Dial., 12(4):509-530.
de Peyer, J. (2016). Uncanny Communication and the Porous Mind. Psychoanal. Dial., 26(2):156-174.

Saturday, July 20, 2019


The Moon was but a Chin of Gold
A Night or two ago—
And now she turns Her perfect Face
Upon the World below—

Her Forehead is of Amplest Blonde—
Her Cheek—a Beryl hewn—
Her Eye unto the Summer Dew
The likest I have known—

Her Lips of Amber never part—
But what must be the smile
Upon Her Friend she could confer
Were such Her Silver Will—

And what a privilege to be
But the remotest Star—
For Certainty She take Her Way
Beside Your Palace Door—

Her Bonnet is the Firmament—
The Universe—Her Shoe—
The Stars—the Trinkets at Her Belt—
Her Dimities—of Blue— 

Thursday, July 4, 2019

4th of July, Citizens and Immigrants

No one needs to be reminded that, after killing off its Natives, our country was built by immigrants. Sometimes we forget, though, that those groups whose arrivals preceded other groups’ have historically ‘othered’ the later arrivals, and with the added intent to bar citizenship to people different in religion or country of origin or race, despite these characteristics are protected from discrimination under the law. Asylum seekers, too, have legal protection.
On The Daily Show withTrevor Noah (Sept 27, 2018) America Ferrera (actor, author --“American Like Me,” -- activist, and director) said  “...women and people of color and all sorts of marginalized people in this country are feeling we should be able to walk into spaces with our whole selves. We shouldn’t have to strip away the pieces of us that aren’t accepted by the mainstream culture to exist and be accepted in spaces. For me that means I’m an actress, that means I’m a director,  that means I’m a producer, that means I’m an engaged citizen and I get to be all of those things no matter what room I walk into.” [I have always liked this woman, in part because her immigrant parents so admired this country that they named her after it!]
The Second paragraph of our sacred Declaration of Independence says
We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. 
Fortunately, for women the liberal interpretation now includes us, but, of course, we are not all created equal. Some of us are taller or faster or smarter or more symmetrical. What is unalienable is that we are all entitled to equal treatment and protection under the law. This latter truth is often circumvented. Those with money are, as we know, treated and protected better than those without money. If USA could remedy this and have equal treatment under the law, perhaps global citizens could better be recognized as deserving of human rights, no matter their country of origin. If America wants to spread its values around the world, perhaps it should start at home.

Friday, June 28, 2019


Last week the American Psychoanalytic Association (APsaA) apologized for its part in formerly pathologizing homosexuality and for the “discrimination and trauma” doing so had inflicted on those who sought help from psychoanalysts. In 1991 homosexuality, under threat of an anti-discrimination lawsuit, was no longer classified as a mental disorder. The APsaA now stands against conversion therapy and supports LGBTQ civil rights.
Earlier this month NYC’s Police Commissioner apologized for the raid, fifty years ago today, on Stonewall Inn, a popular bar-nightclub for gay men and women. A riot ensued when patrons fought back by throwing bottles at police officers, and, days later, demonstrations for the civil rights of LGB Americans took place. Stonewall sparked the Gay Pride movement. President Bill Clinton was the first president to acknowledge Pride month in 2000.
Virginia Goldner said:
[I]n considering the history of gender-variant subjects, I am more struck by the trauma of stigma, which, along with the isolation of being/feeling different, and of coping with the unrelenting, embodied self-alienation of gender dysphoria, takes a far greater toll on the soul than I had initially understood. I still think it is these experiences of self-alienation, combined with an estrangement from one’s very own breathing body, that constitute the foundational trauma of gender variance.
Corbett, K. Dimen, M. Goldner, V. Harris, A. (2014). Talking Sex, Talking Gender—A Roundtable. Studies in Gender and Sexuality, 15(4):295-317.

Sunday, June 23, 2019

Reading Aloud and the Third

Children’s book author and two-time Newberry medalist Kate Dicamillo [Louisana’s Way Home -- described as “a story of discovering who you are — and deciding who you want to be”] recounts a momentary event that changed her outlook forever. 
In 1972, when she was eight years old at Clermont Elementary School in Clermont, FL, her second grade teacher Mrs Boyette was reading aloud to the class from Island of the Blue Dolphins. She says [Nov 19, 2018, PBS NewsHour, IMHO],
“I am literally on the edge of my seat ...caught up in the wonder of it all. I am a kid who loves a story. But also in that second grade classroom seated not too far away from me there’s a class bully. Because I am so terrified of this boy, he does not even seem real to me, he is in my mind less a boy and more … a monster. ...and I notice that he is listening too, that he is engaged by the story too, that he, like me, is leaning forward in his seat and listening with his whole heart.  I stare at him, open-mouthed. I’m struck with the sudden knowledge that this boy that I am so afraid of is, in fact, just like me. He is a kid who likes a story. The boy must feel my eyes on him because he turns. He sees me seeing him and something miraculous happens: he smiles at me, really. And then another miracle: I, unafraid, smile back. We’re two kids smiling at each other.
“Why have I never forgotten this small moment? Why, almost 50 years later, do I still recall every detail of it? I think it’s because that moment illustrates so beautifully the power of reading out loud. Reading aloud ushers us into a third place, a safe room. It’s a room where everyone involved, the  reader and the listener, can put down their defenses and lower their guard We humans long not just for story, not just for the flow of language, but for the connection that comes when words are read aloud. That connection provides illumination. It lets us see each other. When people talk about the importance of reading aloud they almost always mean an adult reading to a child. We forget about the surly adolescent and the confused young adult, and the weary middle aged, and the lonely old. We need it too. We all need that third place, that safe room, that reading provides. We all need that chance to see each other.”

Wednesday, June 19, 2019

Reparation, a way towards repair

H.R. 40 seeks to establish a commission to study the effects of slavery and its subsequent racial and economic discrimination, and its physical, economic, and psychological impact on African Americans today, and then make recommendations for repair and reconcilliation. In 1989 John Conyers, (D) Rep. MI, introduce H.R. 40 (40, from 40 acres and a mule) and today it might finally have some teeth. Therapists familiar with rupture and repair might have some insights to offer the US Congress on healing. While a few presidential candidates have come out in favor of reparation, one, Marianne Williamson, is an author and activist who actually knows a few things about healing the soul of our nation evident in her ideas about poverty alleviation, peace building, women’s advocacy, and feeding the hungry, to name a few.
Therapists are well aware of how insidious and pernicious intergenerational transmission of trauma is on families across time.  Attachment research and Infant-mother research have shown that anxiety and dissociation are not merely inherited but are created from experience, that is, encoded in the brain and built within central and peripheral neuronal connections that become a default position for future experience. Huge retrospective and prospective studies have documented the physical and psychological consequences of adverse childhood experiences (ACE).
Is any trauma so heinous or span centuries as slavery did in the United States? Dehumanization of people, the calculated splitting up of families (seen recently at our southern border), the terrorization to body and sense of self (continued by Jim Crowe segregation laws, the KKK, lynchings, and today, the inequitable incarceration and shooting of black men) all create long lasting sequelae to traume. Reparations (more than eigthy billion dollars) were paid by Germany to Jewish Holocaust survivors and refugees. The USA compensated Japanese interned during World War II (Civil Liberties Act of 1988). Is there a way to recognize the early economic prosperity of America established on the backs of unpaid slave labor that can heal the soul of America?

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