Attachment in Clinical Practice

The third Development course in the TBIPS curriculum is ‘Attachment and Affect.’ It utilizes David J. Wallin’s (2007) book Attachment in Psychotherapy (Guilford Press, NY) with its accessible style and clinically applicable explanations.

In Chapter 11, Wallin explicates how patients require our empathy, but they also need to experience within relationship with us that overwhelming feelings can be managed. Because attachment is affect regulation, patients need to experience us as able to cope with their most difficult feelings, feelings their parents may have rejected, ignored, or punished. Therapists, in order to be able to welcome in and cope with their patients’ difficult feelings, must, of course, be capable of managing their own in order to consistently communicate a desire to understand and to help.

When failings or ruptures occur, the therapist must often be the one to initiate repair -- through intersubjective negotiation -- so that the patient can experience that the relationship with the therapist can survive disappointment, anger, and disagreement (difference). This repair of ruptures strengthens the ‘secure base’ and the patient develops an increasing “confidence that the relationship can be relied on to contain difficult feelings and help resolve them.”

Managing affects together (mutual regulation) not only embodies the secure attachment, it may also, for the patient, maybe for the first time, give a new experience of having one’s feelings and intentions be consistently of interest and concern to the other (the therapist). These new experiences challenge a patient’s expectations that others are disinterested in their feelings and inner lives.

Also in Chapter 11 we find an introduction to attachment styles seen in adult patients (using separation and termination responses as indicative). Relying on the momentous research of Ainsworth in the Strange Situation and of Main in the Adult Attachment Interview (AAI) and the Strange Situation, Wallin describes what may be seen in insecurely attached (dismissing, preoccupied, and unresolved) adult patients, and imagines their attachment styles in childhood (avoidant, anxious-resistant, and disorganized, respectively).

Avoidant attachment styles, as observed in one year old toddlers in the Strange Situation, avoid turning to caregivers for comfort when distressed and avoid showing distress (emotion) because they have already learned from experience that their parents will be dismissing of their distress. These toddlers are at risk as adults to be dismissing of their own feelings and desires and to take comfort in solitary endeavors. Their narratives may be brief, and devoid of emotional language, as seen in obsessive persons.

Preoccupied adult patients, corresponding to an anxious-resistant or anxious-ambivalent attachment style in toddlerhood, may be intensely expressive of their emotions, having learned in childhood that it took a giant display to get the attention of their preoccupied caregivers.They often see themselves as helpless to external forces. Their narratives are often copious, tangential, and hard to follow.

Unresolved adult patients can often show lapses in communication as exhibited by changes in self states (dissociation) and lapses in coherence and logic. They likely had disorganized styles of attachment as toddlers with caregivers who had unresolved trauma in their own childhoods [leading the unresolved parent to behave in a frightened or frightening manner].

Right brain-to-right brain Communication and Attachment

From Bowlby we learn that attachment is a primary motivation (for survival), not secondary to oral gratification (feeding) as Anna Freud and Klein surmised. Bowlby also highlights the importance of environmental factors in human development.

Schore states that attachment is affect regulation, achieved especially through right brain-to-right brain communication. Beebe’s research shows us that infants ‘talk’ even before they have words and that, for secure attachment to develop, the caregiver must be able to decode the infant’s communications. If the caregiver is contingently responsive to the baby’s cues, then the baby’s social and cognitive development is enhanced. The infant’s emotional, social, and cognitive development depends on being recognized both in positive moments and in distress (negative) moments.

Preoccupied mothers  are less able to respond to their babies’ cues and less able to empathize with their babies’ distress. This can lead to insecure attachment. (avoidant attachment with dismissing--of the child’s distress-- mothers; anxious-resistant attachment with preoccupied mothers; and disorganized attachment with frightened/frightening --with a history of their own childhood trauma-- dissociated mothers).

Interactions in the early months of life can predict attachment styles at one year and predict social and academic success in the school years. The flexible, rapidly developing brain of the infant wires itself based on environmental (social relationship) interactions.

Attachment and Affect course at TBIPS

Because, this week, the Tampa Bay Institute for Psychoanalytic Studies’ second year class will begin its Attachment and Affect course, I thought this would be a good time to remind students about Shore’s (2001) ideas on attachment as affect regulation: 1. Affect regulation and the unconscious are primarily the purview of the right hemisphere of the brain.  [Here Schore means by unconscious that which is automatically processed by mostly subcortical structures, and does not refer to Freud’s dynamic unconscious where a conflict was once conscious, however fleetingly, and then repressed]. 2. The essential task of the first year of life is to establish a secure attachment to a primary caregiver.

The primary caregiver facilitates affect regulation and hence attachment through contingent responsivity, attuning, synchronizing, up or down regulating accordingly, repairing ruptures, and by managing her/his own affect. [In doing so s/he contributes to the infant’s brain growth, stimulating neuronal connections and important neurotransmitters for self control and affect regulation, while promoting in the infant a sense of going on being and meaning making.]

The patient must form an attachment (part of the working or therapeutic alliance) with the therapist. This attachment comes into being via affect regulation. This attachment may explain the therapeutic efficacy seen across differing theoretical schools. Schore writes, “The major contribution of attachment theory to clinical models is its elucidation of the nonconscious dyadic affect-transacting mechanisms that mediate a positive working alliance between the patient and the empathic therapist.”

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.

Substance Abuse is an attempt at Affect Regulation

First, a Happy New Year! to the readers after a holiday break from posts here on Contemporary Psychoanalytic Musings.

This morning, January 12, 2019, the Tampa Bay Psychoanalytic Society hosts me-- Lycia Alexander-Guerra, MD-- and a colleague, Paulina Robalino, LCSW, to speak about how psychoanalytic psychotherapy contributes to substance abuse treatment in a talk “A Psychoanalytic Dimension to Substance Abuse Treatment.” My premise is:

Substance abuse is an attempt to affect regulation. The inability to self regulate affect is a  result of failure in infancy and childhood of sufficient experiences with mutual regulation. Psychoanalytic psychotherapy is about mutual regulation and therefore is an important adjunct to treatment of people with substance abuse problems.

Joyful and loving interactions with others stimulate feel good chemicals in the brain (dopamine, serotonin, oxytocin) and the soothing or calming of distress/stress prevents ‘priming’ of the autonomic nervous system -- with its sympathetic and parasympathetic fight-flight-freeze reactions-- by reducing cortisol. Affect regulation (e.g. up-regulating a lethargic, passive infant, or down-regulating a distressed infant) of adverse childhood experiences protect from (decrease the risk for) all kinds of maladies: cardiac and pulmonary disease, cancer, depression, anxiety disorders like PTSD, and, substance abuse.

Psychoanalytic psychotherapy today recognizes the the importance of right brain communication, attachment, and affect regulation in bringing about a more coherent, cohesive, continuous sense of self. By participation in mutual regulation of affect, both members of the analytic dyad have the physiological experience of increased dopamine and oxytocin, ‘exercising’ the brain to more easily produce these neurotransmitters, and increasing the capacity for self regulation. An improved sense of self and an increased capacity for self regulation are important assets on the road to recovery.