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.

The Local Level (and the negotiation toward a path of shared intention)

The candidate/presenter in the Continuing Case Conference started out warning the class that in taking process notes she had gotten confused about who had said what. It turns out that this comment would foreshadow the theme of the session.

The patient had cancelled, due to her work schedule, an appointment with her specialist for a medical concern that warranted follow-up. The therapist had already been concerned about the patient’s possible, serious medical problem, but had not before said anything to the patient about her worries. In this session, the therapist makes her concern explicit, then asks a couple of questions: do your parents know? Were there other reasons to cancel besides work? After this interchange there was some silence. The patient commented that she will bring a letter she is writing to the next session so that the two will have something to discuss. The therapist offered to discuss the process of the letter’s composition. The patient declined, saying she would bring it in when completed. More silence. The therapist inquired if the silence is experienced as a punishment [there is a history of the patient’s mother giving the patient the ‘silent treatment’ when angry at the patient.] The patient says she used to feel that way with the therapist but not anymore. [a new way of being together had already transpired]

The therapist then says she has something she would like to discuss [the patient has offered something, the letter, to bring in to discuss, now the therapist reciprocates, as the two move along the same path toward shared intention ---to not ‘suffer in silence?’], a recent session that had an effect on the therapist and possibly on the patient, but worries she (the therapist) will be too much like the patient’s mother, always setting the agenda. The patient asks if it is appropriate to ask what are the therapist’s feelings about the patient. The therapist explains that what is between them is ‘fair game’ to discuss, and using the word “mutuality,” discloses relief that she (the therapist) is not “crazy” (a word and worry often used by the patient) for they both are on the ‘same page’ about having accidently seen each other in public places. The patient is happy about this mutual understanding but says she prefers the word “solidarity” to “mutuality.”

The class mused about the colloquial (in the therapist’s city) connotations of the word ‘solidarity’ which includes ‘an otherness to our togetherness.’ The class --  aware of the patient’s fears that her Self and her agency would be subsumed under the mother’s -- noted how the patient helps co-create the boundaries between herself and her therapist. The class discussed how a new way of being together [the patient can assert her own agency for the therapist can reflect and make explicit her own contributions to enactments], that is, a change in implicit relational knowing is slowly being forged despite the therapist being pulled into micro-enactments to be concerned, advise, participate, or intrude. The crux of the negotiation has been about moving toward a shared intention. 

The gestalt or arc of the session had been the slow, steady, quiet negotiation around ‘Can we be close and still be separate?’/ ‘May we be close and I not have to subsume my Self and my agency?’  (the theme) While it may have seemed to the therapist and to the class that not very much was happening in the session, it turns out -- as the Boston Change Process Study Group notes -- that change in implicit relational knowing can also, maybe usually, occur even in the quieter moments, and not only in the moments of heightened affect (now moments) and their potential, subsequent moments of meeting.

Change in Psychotherapy: A Unifying Paradigm. (2010). The Boston Change Process Study Group. New York: Norton.

Fittedness and Implicit Relational Knowing: What is Mutative

In co-creating fittedness, the therapist and the patient implicitly move toward a shared intention. In a beautiful explicit, concrete example, a colleague shared how she and a pre-teen, female patient were drawing a story together on a large whiteboard [an example of the therapist joining or following the patient]. After awhile, the young patient became embarrassed and moved away from the shared task, but then, looking over her shoulder and seeing the therapist still drawing, the patient returned to the whiteboard for some finishing touches [an example of the patient joining the therapist]. That is, the two moved closer and closer toward a shared intention. Moving toward a greater ‘fittedness’ leads to an increased coherence within the dyad, which, in turn, expands implicit relational knowing.

Expanding implicit relational knowing widens the possibilities of how to behave with one another and enriches the repertoire of relational patterns. Likewise, flexibility increases, as does the hope for spontaneity. This is mutative. This is change. Change opens the way to insight, when, after comfortability with a new way of being with an other, one notices that and how things are different.

This is to say that change precedes insight, not follows it.

The Boston Change Process Study Group [BCPSG] has turned psychoanalytic thinking on its head in another way with their explication of how relational patterning is primary and the foundation of psychological life, while conflict and defense are secondary. They cite attachment patterns at age twelve months (seen in the Strange Situation) as evidence for the presence of conflicts and defenses based on relational experiences (because the infant has already apprehended what to expect from the caregiver). For example: an infant with avoidant attachment has learned it cannot count on the caregiver to soothe it when distressed and so appears to have little affect [defensive] while seeking objects to soothe itself; or, conflict is evident in disorganized attachment where the infant reaches for its mother while simultaneously backing away from her.

Change in Psychotherapy: A Unifying Paradigm. (2010). The Boston Change Process Study Group. New York: Norton.

Continuing Case Continues? and disruptions, and continuity of sense of self

There was today in class a lot of confusion on the instructor’s part. Even if we get past the limitations imposed by differing accents, by the teleconferencing connection, and by this instructor’s hearing impairments, there remains that the instructor could not sort out when the presenter was talking about what occurred in the session explicitly between patient and therapist and what was being related from the presenter’s mind as hypotheses and as background information about the patient and the treatment for the class to know. [To this instructor’s relief, the instructor was not the only one confused about ‘what is going on around here’ in the class.]  So we decided to discuss together what was going on. [Unfortunately, the presenter was not able to get through the session she had looked forward to presenting; a melancholy choice: choose one, lose the other.]

By addressing in class the process instead of content, we were able to glean some useful ideas.

Quoting one classmate, we could ask: What belongs to whom? Whose ‘language’ is spoken? (whose desire? [a topic of the earlier course]) and Who am I?, all of which might relate to the patient, the patient vis a vis her parents, the therapeutic dyad, and to the class. This same classmate noted that the disruptions might be related to the session (as well as to the presentation), specifically to the possible dissociated self states of the patient coming into the session, threatening continuity of self and of session. Another classmate noted a possible dilemma between fusion and individuality for the patient, that is, the patient experiences an attachment as having to lose the self or part of the self if she is to maintain a connection. (The presenter confirmed this with an example from the session). There is also the Adult Attachment Interview research which found an incoherent narrative is indicative of insecure attachment, which the patient here certainly experienced with her intrusive mother. Lastly, the instructor’s repeated attempts to clarify what the presenter was saying caused not only too many  interruptions (discontinuity) but also had the presenter feeling scrutinized just as the patient had felt so micromanaged by her mother.

All this by way of saying what the reader already knows: process is as important, maybe more so, as content; class process may reveal valuable information about the patient’s inner life; parallel process exists; instructors need to be more mindful of how her desire affects the presenter’s; and much more.

Holding in mind: Dreams in Continuing Case

So our therapist, having recently dreamed about her patient (see post of 11-28-18), opens the door for reciprocity and inquires about the patient’s dreams, particularly dreams about the therapist. The patient, red-faced, shares a previously unshared dream from three months earlier:

I am in a session with you and I come toward you to kiss you. As I get closer, you turn into my mother. I don’t stop but go ahead and kiss you. Suddenly I am my room in my childhood home and you have turned into my father. The scene changes again and I am at my mother’s childhood home and I am kissing a man.

The patient says she woke up from this dream very upset, more upset than from any remembered dream. The patient asks why therapist made this inquiry. The therapist makes the decision to share her dream with her patient. She makes this decision based on ideas about co-creation and from Philip Bromberg’s idea that the therapist’s thoughts, feelings, dreams, about the patient are the purview, the property, of both the patient and the therapist.

This patient’s [maternal] grandmother, now dead six months, had been safe haven for the patient, protecting the patient from the wrath of the parents. As the therapist is describing to her patient the patient’s grandmother as found in the therapist’s dream, the therapist recalls that this grandmother’s brother, the patient’s maternal great uncle, had been eschewed by the family for his political views and activities. While literally dead, this great uncle was also ‘dead to’ the family as they never spoke of him.

Saving associations to the patient’s own dream for a later time, the therapist asks the patient what it was like for the patient to hear of the therapist’s dream. The patients says it had been a tough week for she had been considering when would be the right moment to come out to her parents; and she had run into her father in public that week while with her female lover. Also, the patient and her mother had had their first, in a very long time, serious conversation, all jokes aside, over coffee that week, and her mother had cried. The patient had not overreacted with her mother and she notes that the mother had to choose between living in a faraway town with her husband or staying with her own mother. Choose one, lose the other.

The therapist notes aloud to the patient a connection: the patient believes she, too, must choose between her parents and her girlfriend (and her Self as a lesbian). Furthermore, there will be the feared additional loss of the therapist, for the patient believes therapy can end after she reaches her last goal of coming out to her parents. The therapist shares her own feelings and dilemma: the pride she has for her patient; the therapist’s own loss when the patient leaves. The patient asks for homework [housekeeping; see post of 11-28-18].

The beauty of this session is the ongoing deepening of the relationship between the patient and therapist. The patient had already been growing (mustering her courage to come out, being able to converse with her mother without overly reacting), and one wonders if the patient implicitly experienced and made use of the therapist holding the patient in the therapist’s mind, made explicit by the therapist sharing her dream of the patient.

A therapist's dream about her patient; Continuing Case continues

A therapist has a dream about her patient:

I was waiting for her to come to the session but the therapy room was in my home. Before she came I was trying to make my bed because my stuff was all around and I can see it is my childhood bedroom, the one I used to share with my brother. There are two beds and I am trying to make my own. I have a conversation with my mother, telling her not to interrupt us. My mother says she is not sure whether she will or not. I am setting boundaries with my mother, saying, “No, you won’t!” My patient is coming with her mother and her grandmother. There is a table between us, my patient sitting next to me; on the other side of the table is her mother and grandmother. All the time I am thinking there is no father [here], only the mother and the grandmother. It is as if I am counseling parents, as if my patient is not an adult and I am talking to two parents about a child. At the end of the session the patient asks me for a prescription to protect her from having to do [house]work [for her mother]. I say, “Okay, [names patient], I could write this for you but then it would mean you have depression or withdrawal [can’t handle work because you are withdrawn]. You can’t handle the job, otherwise I can’t prescribe what you are asking at this point.” The patient’s mother says, “She would not have to ask for this prescription if she would have sexual relations with a man.” We [patient and therapist] looked at each other and laughed.

The Continuing Case class noted that the burden of the load of [house]work in the treatment had been mostly on the therapist’s shoulders, where there had been a noticeable asymmetry. The therapist reminds the class how in a recent, previous session the patient had mentioned she now felt more “equality” between herself and the therapist [see post on 11-8-18]. The patient had been able to say ‘no’ to her mother but was, as yet, unable to tell her parents that she is a lesbian. In fact, the patient’s last goal in therapy is to come out to her parents, after which she can terminate the treatment. In the dream, it is the therapist who stands up to her own mother. In the dream, the patient is requesting the therapist’s “prescription” perhaps like an alibi or excuse to not have to do -- in the parents’ eyes --  the work of a woman, that is, not have to marry a man. Perhaps the therapist in the dream is saying that, should the patient succeed at circumventing the parental demands for heterosexuality by coming out to them, then, were the patient to be also depressed and withdrawn, the therapist would have an excuse to keep the patient in treatment.

It seems that the therapist’s dream about her patient condenses the patient’s difficulties while also resonating with the therapist-as-daughter issues. The patient’s mother, upon falling in love with the father, had had to leave her own mother and move far away. In parallel, the patient expects to be abandoned by her own parents should she choose to openly love [a woman]. To be forced to love a man in order to maintain ties with her parents would cause depression and withdrawal in the patient. The therapist dreams a way for the patient to stay in relationship with the therapist and the treatment, though not a perfect solution. These themes, fresh in the therapist’s mind, may now be revisited and reconfigured together in future sessions.

Misogyny in psychoanalysis

    Never was the contrast between classical and contemporary psychoanalysis more stark than in the chapter chosen for a beginning course in technique* by CAPA (China American Psychoanalytic Association). The chapter --- (#2) “Assessments, Indications and Formulation” ---  appears in Long-Term Psychoanalytic Psychotherapy, Third Edition (2017) by the renowned psychiatrist and psychoanalyst Glenn O. Gabbard, MD where he formulates the case of a 38 year-old woman “to explain the patient’s clinical picture.” 
The patient presented with depression and the beginning of a new, troubled, heterosexual relationship. Her mother ”had never really been able to take care of her because her mother was emotionally unstable and upset all the time.” Her father was an alcoholic and a womanizer who would comment on the patient’s looks, and the patient was contemptuous of him. The parents divorced when she was 12 years old. The patient had been using alcohol from a young age and had intercourse at age 13 years with a man who bought her alcohol. Subsequently she began using illicit drugs. She described herself as “highly ‘promiscuous’” and said she is addicted to alcohol and sex.

    Gabbard makes a lot of the woman’s sexualness and seductiveness, in her dress and in her attitude toward her male therapist.  In his formulation, his “psychological hypothesis” is: “Ms. A grew up in a tumultuous childhood situation where she felt neglected by her mother, so she attempted to get love and admiration from her father by attending to her appearance and sexualizing their relationship.” Even if we decide to ignore the patient’s contempt for her father--- and his behavior toward her and others--- and surmise that a part of her, of course, is longing to be loved and recognized by him, nowhere does Gabbard mention in his formulation her rape at age 13. Instead, there appears to be an implicit blaming of her.

    Other than “a tumultuous childhood situation where she felt neglected by her mother” Gabbard does not find the history of this rape significant enough to include in his formulation. He does not include anywhere in his formulation anything about insecure attachment or the dissociation and incoherence that result when a mother could not attune, regulate or protect the patient as a little girl, all of which likely contributed to the patient’s inability to understand the intentions of others in a self protecting way. That the patient seeks recognition and tenderness seemed to have been confused [Ferenczi] by Gabbard, as seen in his emphasis on ‘sexual’ behavior. Would a clinician not wonder if her “promiscuity” were not an enactment of her childhood sexual traumas [plural, as I imagine more than one]. Gabbard's formulation at best indicates he is wedded to drive and Oedipal theory and at worst intimates that the child unconsciously orchestrated her own rape as a consenting [as if the age of consent in an equitable and civil society were 13] seducer of men; and why? because she longed for her father's attention. And what about her mother’s attention in this formulation?

Are we still living in this kind of world?

* [does ‘Technique’ imply we apply one set of actions to all patients?]