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. 

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.)

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. […]

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.