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