Attachment Theory and Psychotherapy
by Daniel Jay
Sonkin, Ph.D.
Published in the The Therapist, a publication of
the California Association of Marriage
and Family Therapists January/February, 2005.
Last
year I co-authored a book chapter with Donald Dutton, entitled Treating Assaultive Men from
an Attachment Perspective (Dutton and Sonkin, 2003). This chapter was excerpted in The Therapist,
September/October, 2003. In it we gave
an overview of domestic violence and attachment theory, explored our rationale
and clinical approach to treating perpetrators from this developmental
perspective. In this article, I would
like to speak about attachment theory and its application to psychotherapy in
general. I will first begin with an
overview of attachment theory and the assessment of attachment status. Then, I will discuss other contemporary
authors who are exploring the clinical aspects of attachment theory. The article will finish with how I believe
attachment theory may inform our understanding and development of the
therapeutic alliance.
Attachment Theory: An Overview
John
Bowlby used the term "attachment" to describe the affective bond that
develops between an infant and a primary caregiver. He believed that the "attachment
behavioral system" was one of four behavioral systems that are innate and
evolutionarily function to assure survival of the species. The quality of attachment evolves over time
as the infant interacts with his/her caregivers. The type of attachment, or attachment status
of the infant toward the caregiver is partly determined by the interaction
between the two and partly by the state-of-mind of attachment (vis a vis their
own attachment figures) of the caregiver.
In his ground-breaking three volumes on attachment and loss (Bowlby,
1969, 1973, 1980), Bowlby wrote that attachment bonds have four defining
features: proximity maintenance (wanting to be physically close to the
attachment figure), separation distress, safe haven (retreating to caregiver
when sensing danger or feeling anxious), and secure base (exploration of the
world knowing that the attachment figure will protect the infant from
danger). Attachment relationships
evolve over the first two years of life and beyond, but most importantly these
early attachment relationships overlap with a time of significant neurological
development of the brain. (For more
information about the neurobiology of attachment, see Siegel (1999) and Schore
(2003)). Bowlby describes a series of
stages that attachment develops: preattachment, attachment in the making,
clear-cut attachment and goal corrected partnership. In the Handbook of Attachment (1999), Cindy
Hazan and Debra Zeifman take these stages and apply them to the development of
adult pair bonds.
Alan
Sroufe (1995), of the University
of Minnesota
Attachment
is not a one-way street. As the
caregiver affects the infant, the child also affects the caregiver. Edward Tronick (1989) of the University of
Massachusetts, refers to this process as "mutual regulation." Daniel Stern, author of the Interpersonal
World of the Infant, (1985) refers to the "attunement" of the
caregiver: where the parent is sensitive to the verbal and non-verbal cues of
the child, and is able to put himself/herself into the mind of the child. Each of these writers view attachment as
central to the capacity of emotion regulation.
Mary
Ainsworth was the American psychologist who brought Bowlby's theory to the
United States and developed a method of assessing infant attachment. In her landmark book, Patterns of
Attachment: A psychological study of the strange situation (1978), she
describes this widely used protocol, the strange situation, and the patterns of
secure and insecure attachment.
Originally three patterns were observed, secure, anxious avoidant, and
anxious ambivalent, but later on Mary Main and Judith Solomon at the University
of California in Berkeley described a fourth category, disorganized (1986). The
anxious-avoidant and disorganized types sought attachment but experienced
anxiety as a consequence of attachment.
Also, both experienced anxiety at the disappearance of the mother and
were difficult to soothe upon reunion.
The disorganized children were particularly ambivalent upon reunion with
their attachment figure, both approaching and avoiding contact. Bowlby, in his book Attachment and Loss,
(1969) described these children as "arching away angrily while
simultaneously seeking proximity" when re-introduced to their
mothers. Interestingly, although the
anxious-avoidant children seemed content in the absence of their attachment
figure and not particularly interested in reconnecting upon reunion, when
physiological measures were taken, these children were quite anxious during
separation, but somehow learned to repress their feelings.
In
the 1980s, the field of adult attachment began to evolve. This occurred for several reasons. First, many attachment labs, such as the one
at the State University of New York at Stony Brook, were conducting research on
the continuity over time of attachment status, and long term effects of secure
and insecure attachment (Waters, Merrick, Treboux, Crowell, and Albersheim,
2000). As the children assessed in the
strange situation (at ages 12 or 18 months) grew up, data on the continuity of
attachment patterns began to emerge. In
addition, social psychologists such as Phil Shaver at the University of
California in Davis, and clinical researchers Phil and Carolyn Cowan at UC
Berkeley, became interested in attachment in adult relationships. For example, the Cowans (1999) have
extensively studied the transition to parenthood and how attachment status
affects the process. Phil Shaver was one
of the first researchers to study how attachment status affects the dynamics of
couple's relationships (Hazen and Shaver, 1987). More recently, he along with Mario Mikulincer from the
Department of Psychology at Bar-Ilan University in Israel, has studied the
effects of secure-base priming with insecure individuals on their prejudices
and perceptions of people who do not belong to their ethnic group (Mikulincer
& Shaver, 2001). The terminology of
adult attachment is somewhat different from infant attachment. Secure children are referred to as secure or
autonomous adults. Anxious-avoidant children are referred to as dismissing
adults. Anxious ambivalent children are
referred to as preoccupied adults.
Disorganized children are referred to as disorganized or unresolved adults. There is also a category of children and
adults, referred to as "cannot classify" because particular patterns
do not emerge in their assessment. This
represents a very small percentage of the population.
Three
important findings have emerged from the research in adult attachment. First, is that the attachment status of a
prospective parent will predict the attachment status of their child to that
parent: with as high as 80 percent predictability (van Ijzendoorn, 1995). Second, although changes over time can
influence the attachment status of a child, there is a strong continuity
between infant attachment patterns, child and adolescent patterns and adult
attachment patterns. Changes in
attachment status can occur in either direction (secure to insecure, insecure
to secure), and in fact, the term "earned secure" has been used to
describe individuals who experience malevolent parenting (and therefore one
would expect an insecure attachment status), but have risen above those
experiences and who are assessed as securely attached (Main and Goldwyn,
1993). However, for the majority of
individuals, the manner in which they learned to manage anxiety early on in
life will continue unless their circumstances change or other experiences
intervene. For many people, the coping
mechanisms may become more sophisticated, but the net result (over-activating
or under-activating in the case of insecure attachment, and modulation with
secure attachment) will essentially continue.
Lastly, adults assessed as having an insecure state-of-mind with regard
to attachment have greater difficulties in managing the vicissitudes of life
generally, and interpersonal relationships specifically, than those assessed as
securely attached (Shaver and Mikulincer, 2002).
Assessing Attachment
There
are two general methods for assessing attachment in adults, interview methods
and self-report scales. The most common
interview method is the Adult Attachment Interview (AAI) developed by Mary Main
and her colleagues at the University of California at Berkeley (Main and
Goldwyn, 1993). The Adult Attachment Interview contains 20-questions that asks
the subject about his/her experiences with parents and other attachment
figures, significant losses and trauma and if relevant, experiences with their
own children. The interview takes
approximately 60-90 minutes. It is then
transcribed and scored by a trained person (two weeks of intensive training
followed by 18 months of reliability testing). The scoring process is quite
complicated, generally but it involves assessing the coherence of the subject's
narrative. Mary Main describes a
coherent interview in the following way.
"...a coherent interview is both believable and true
to the listener; in a coherent interview, the events and affects intrinsic to
early relationships are conveyed without distortion, contradiction or
derailment of discourse. The subject collaborates with the interviewer,
clarifying his or her meaning, and working to make sure he or she is
understood. Such a subject is thinking
as the interview proceeds, and is aware of thinking with and communicating to
another; thus coherence and collaboration are inherently inter-twined and
interrelated" (Slade, 1999, page 580).
Some
sample questions from the AAI are:
1. I'd
like you to choose five adjectives that reflect your childhood relationship
with your mother. This might take some time, and then I'm going to ask you why
you chose them. (Repeated for father)
2. To
which parent did you feel closest and why? Why isn't there this feeling with
the other parent?
3. When
you were upset as a child, what would you do?
4. What
is the first time you remember being separated from your parents? How did you
and they respond?
What
is it about the coherence of a life story that reflects the attachment status
of the subject? There are differing
ideas for this, but what seems like the most plausible explanation to this
writer is, when telling one's life story, it is likely to generate subtle and
not so subtle emotions about those experiences.
How one regulates those emotions is going to, in part, determine the way
the story is told. Reading the
transcripts of securely attached individuals, their stories are coherent in the
manner Main described above. Dismissing
adults tend to have extremely brief stories.
Many don't recall memories of childhood.
Those who have untoward experiences either deny their occurrence or
rationalize their negative feelings and claim that those experiences made them
stronger and more independent.
Preoccupied individuals tend to get caught up in negative, analytic
discussions of their past and therefore their transcripts tend to be
excessively long. Their past tends to
intrude on their present discussions of attachment and can be extremely
devaluing or idealizing of their attachment figures. Their narratives are entangled and hard to
follow. Disorganized individuals tend to
have lapses in the monitoring of reasoning and discourse in their interview
when discussing loss or experiences with abuse (Hesse, 1999). The AAI protocol is available at the Stony
Brook Attachment Lab web site at:
Another
method similar to the AAI was developed by Peter Fonagy and Mary Target of the
Psychoanalysis Unit of University College, London. They use the AAI questions, but the
transcript is analyzed from from the perspective of Òreflective function.Ó Scoring the narrative involves assessing the
speaker's ability to reflect on their own inner experience, and at the same
time, reflect on the mind of others (Fonagy and Target, 1997).
Another
promising method of assessing adult attachment is the Adult Attachment
Projective (AAP) developed by Carol
George of Mills College, and Malcolm West of the University of Calgary (George
and West, 2001). The test consists of eight drawings (one neutral scene and
seven scenes of attachment situations).
According to the authors, "the drawings were carefully selected
from a large pool of pictures drawn from such diverse sources as children's
literature, psychology text books, and photography anthologies. The AAP
drawings depict events that, according to theory, activate attachment, for
example, illness, solitude, separation, and abuse. The drawings contain only sufficient detail
to identify an event; strong facial expressions and other potentially biasing
details are absent. The characters depicted in the drawings are culturally and
gender representative" (page 31).
Like
the AAI, the subject's responses are recorded and transcribed and then scored
based on the coherence of the responses.
Authors use some similar and different scales from the AAI coding
process. According to the authors the
AAP takes less time to administer and much less time to score, which makes it
more useful for clinicians. Unlike the
AAI, the AAP is geared toward clinicians as opposed to only researchers in
attachment. For more information on the
AAP see their web site at http:
//www.attachmentprojective.com/.
The
other method of assessing adult attachment is with self-report scales. The Experiences in Close Relationships Scale:
Revised, developed by Phillip Shaver and his colleagues (Brennan, Clark and
Shaver, 1998), is a self report scale that measures attachment security on two
dimensions, anxiety and avoidance. The
first scale developed had three questions.
Since then, it has been expanded to 36 questions. Their most recent version was based on a
scale developed by Kim Bartholomew: the Relationship Status Questionnaire
(Bartholomew and Horowitz, 1991).
Because they have many of the same items, these two scales correlate
highly with one another (Shaver, Belsky and Brennan, 2000). One important
difference between their two scales is in how they deconstruct attachment. Shaver and his colleagues view attachment on
two continuums, anxiety and avoidance.
How an individual scores on each of these subscales will determine their
attachment classification. Bartholomew,
on the other hand, deconstructs attachment also on two continuums: working
models of self and others (either positive or negative) (Bartholomew and
Moretti, 2002). Her approach was more in
line with Bowlby's initial cognitive conceptualization of attachment. However, what these two tests reveal is that
the cognitive (Relationship Status Questionnaire) and emotional/behavioral (Experiences
in Close Relationships Questionnaire) dimensions are all linked with regard to
attachment. The advantage of these self-report scales is that they are easy to
administer and score, and therefore clinicians do not need special training in
their use.
All
of Shaver's scales can be accessed at the UC Davis Attachment Lab web site at; http:
//psyweb2.ucdavis.edu/labs/Shaver/.
In fact, Shaver has an online version of his Experiences in Close Relationships
scale that therapists and clients could take and then receive their results
immediately. This can be found at http:
//www.web-research-design.net/cgi-bin/crq/crq.pl or http: //www.yourpersonality.net. Bartholomew's scales can be accessed at her
web site at: http://www.sfu.ca/psyc/faculty/bartholomew/research/index.htm.
Can
attachment status be assessed via a clinical interview? Unfortunately, clinicians are not as
accurate as they would like to think they are.
And the studies of comparing clinician's diagnostic abilities and
psychometric testing support this contention.
But it is my belief that as a clinician gets to know his/her client's
over time, and carefully observe their behaviors and listen to their language,
attachment patterns begin to emerge and can be clearly recognizable. However, this takes time and good observation
on behalf of the clinician. So in the
meantime, using one of the available methods of assessing attachment status is
worthwhile.
Attachment and Psychotherapy
Over
the past ten years, a number of individuals have begun to explore how this body
of knowledge of attachment theory would apply to clinical practice. A number of these writers bear
mentioning. Peter Fonagy, of the
Psychoanalysis Unit of the University College London, has written two
ground-breaking books on integration of attachment theory and psychotherapy: Attachment
Theory and Psychoanalysis (2001) and Affect Regulation, Mentalization
and the Development of the Self (with M. Target, G. Gergely and E.J.
Jurist) (2002). In his books, Fonagy
speaks about the hallmark of secure attachment being the ability to reflect on
one's internal emotional experience, and make sense of it, and at the same time
reflect on the mind of another. One can
immediately see how these capacities are imbued in the infant through sensitive
attunement of the caregiver. When a
caregiver reads the verbal and non-verbal cues of the child and reflects them
back, the child sees him or herself through the eyes of the attachment figure. It is through this attunement and contingent
communication process that the seeds of the developing self are planted and
realized. Insecurely attached individuals lack this reflective function either
because their emotional responses are so repressed as in the case of the
dismissing attachment status or exacerbated as in the case of the preoccupied
attachment status that they are unable to either identify their own internal
experience or reflect on that of the other. When either one of these extremes
are the method of regulating the attachment behavioral system, the capacity for
reflection (on oneself and others) is compromised.
Jeremy
Holmes, likewise an analyst in England, has written the book The Search for
the Secure Base: Attachment Theory and Psychotherapy (2001). Holmes talks at great length about the narratives
of insecurely attached individuals. He
refers to story-making, and story-breaking.
In the case of dismissing attachment, where the story is so restricted
as to reduce the possibility of dysphoric affect, the clinician is helping the
patient create a story that is coherent, full of memory and manageable
affect. In the case of preoccupied
attachment, where anxiety over-runs the client's story in that it becomes
convoluted and saturated with anger and disappointment, the therapist's role is
to help break the negative cycle of the narrative, manage the affect more
effectively and create a story that is balanced and coherent.
Allen
Schore's two most recent books, Affect Dysregulation and Disorders of the
Self, and Affect Regulation and
Repair of the Self (2003) goes beyond integration of developmental
theory and psychotherapy, but also describes the neuroscience of attachment and
how the brain of the parent and infant interact. Schore speaks in depth about the neurobiology
of the developing mind during the first three years of life and how the right
brain processes are integrally involved in attachments and the development of
the self. He spells out very clearly
how insensitive parenting leads to emotion dysregulation patterns in childhood
and later in adulthood. He understands
insecure attachment as emotion dysregulation and therefore the goal of
psychotherapy is to learn new capacities to manage attachment distress: that
psychotherapy is the process of changing neural patterns in the brain, the
right brain in particular.
Daniel
Siegel writes in his book, The Developing Mind: How Relationships and the
Brain Interact to Shape Who We Are (2001), like Schore, he has expanded our
understanding of how attachment relationships and the brain influence each other
respectively. Siegel is particularly
interested in how the right and left brain work together (or don't in the case
of insecure attachment) to create a coherent life story and way of responding
to relationships and life. He takes
complexity theory and applies this to psychological functioning. Complex
systems are the most adaptive and stable, whereas rigid systems are not. His book not only focuses on attachment, but
other related topics such as emotion, memory, trauma, and consciousness. He draws from multiple disciplines to help
the reader understand that no one focus of study, such as psychology, will have
all the answers to important questions, such as "what is mental
health?"
Each
of these authors has expanded our understanding of how to incorporate the vast
body of knowledge that has accumulated in attachment theory into the practice
of psychotherapy. However, many
questions remain unanswered and therefore we are just beginning to understand
this interface. Arietta Slade, of the
Department of Psychology at the City University of New York (1999), sums up the
controversy of whether or not attachment theory is relevant to clinical
practice by stating, "In essence, attachment categories do tell a
story. They tell a story about how
emotion has been regulated, what experiences have been allowed into
consciousness, and to what degree an individual has been able to make meaning
of his or her primary relationships" (p. 585).
If
one way of conceptualizing attachment status is that it is a form of affect
regulation that occurs in the context of relationships in general, and how
individuals deal with emotions associated with separation, loss and reunion
specifically, it seems that attachment theory would be relevant to one of the
most significant areas affecting the work of psychotherapists: the therapeutic
alliance.
The Therapist as an Attachment Figure
Bowlby
believed that intimate attachment to other human beings are the hub around
which a person's life revolves (1969).
From these intimate attachments a person draws his strength and
enjoyment of life. He also believed that one such attachment may be a person's
therapist. Bowlby describes the five
tasks of attachment informed psychotherapy in his book, A Secure Base
(1998). One of those tasks is to explore
the relationship with a psychotherapist as an attachment figure. Bowlby
believed that the therapist would be viewed as an attachment figure regardless
of whether or not the client is aware of this fact. The therapist-client relationship, like the
parent-child relationship will manifest the same four characteristics described
earlier: proximity maintenance (the client will seek the therapist to discuss
problems), separation distress (the client will experience some degree of
distress when needing the therapist and the therapist is not available), safe
haven (will seek the therapist when needing help in resolving distress), and
secure base (will use the therapist as a secure base to explore the inner and
outer worlds of her/his life). Like the
process of developing attachment that occurs in the child-parent relationship,
the developing of the therapeutic relationship will follow a similar process:
preattachment, attachment in the making, clear-cut attachment and goal
corrected partnership. And like the patterns
of attachment that emerged in the stressful Strange Situation Procedure, the
natural ruptures and reunions that occur in the psychotherapy are likely to
activate the attachment behavioral system.
For some individuals who have had particularly untoward experiences in
their family of origins, simply walking into the therapist's office is likely
to cause anxiety. But in this unusual
type of relationship, the client has the opportunity to have these patterns brought
to their attention, reappraise their functionality and learn new methods of
regulating affect.
But
how does one actually facilitate this process?
Siegel (1991), among other things, writes about the non-verbal
communication of primary emotions and the importance of contingent communication
between therapist and client. Contingent
communication begins when Person A sends a signal to Person B: these signals
are both verbal and non-verbal signals (facial expressions, body
movements/gestures, tone of voice, timing and intensity of response, etc.). Person B needs to recognize the signal,
interpret it correctly and send back a signal to Person A. Now this response is not just simply a mirror
of what was received, but Person B sends a message that the original signal was
received, interpreted and is being responded to by the receiver: in other words
"I got it." When this occurs,
the sender feels felt or understood and then the process continues. Siegel contends that contingent communication
is the basis of healthy, collaborative communication and facilitates positive
attachments.
In
psychotherapy, most communication between the therapist and patient occurs on
this non-verbal level. The role of the
therapist is to watch for non-verbal signals (a right brain to right brain
process) and work to interpret them and respond to them appropriately. This seems so elementary and each of us
probably remembers a talk in graduate school about the value of non-verbal
communication. Yet, if what these
writers are telling us is true, then it seems that the ability to read and
interpret these non-verbal signals is more than a therapeutic trick we
occasionally pull out of our bag. It is
the basis of developing the therapeutic alliance, which in turn is the key to
positive therapy outcome.
Daniel
Stern refers to talks about the significance of "now moments"
(2004). These are flashes of
interactions between the therapist and the client that are rich in potential
for change and growth in the client, but also in the therapist and the
relationship as well. Stern describes
the process of therapy as moving along in a somewhat spontaneous and sometimes
random manner until these moments occur.
I think about the time when I was sitting in the car with my then
one-year-old daughter and we were playing with a box. All of a sudden the top fell off and
multicolored glitter spilled all over her lap, my lap and the back seat. We looked at each other intently and then at
the exact same moment we both burst out into laughter. This is when a now
moment is turned into a "moment of meeting." In that moment there is
a deep sense of connection and intimacy. For individuals in psychotherapy who
do not experience those moments, for the most part in their relationships are
missing something important indeed. When
"now moments" are recognized in the context of the psychotherapy,
there is the potential for a deep connection between the participants, and as
the studies have indicated, this is a necessary ingredient for positive
therapeutic outcome.
In
my work with patients, I likewise try to both keenly attune myself to the
client's signals, both verbal and nonverbal, and at the same time attune myself
to my own internal experience. Like the
mutual regulation that occurs between parent and child, a similar process is
occurring in the therapeutic relationship.
Subtle nonverbal cues are picked up and processed by the mind, under the
radar so to speak, but a reaction occurs nevertheless. This is why it is so important for therapists
to be attuned to their own internal emotional/body experience and be able to
represent it in their minds. Likewise, changes in the therapist's state-of-mind
will be picked up by the client and will either exacerbate or reduce their
anxiety. This close attention to the process
of contingency is critical to the development of the therapeutic
relationship. When a patient feels by
the other, they experience a deep sense of being understood, which contributes
to positive feelings associated with close relationships.
The
other important aspect of this process is the therapist's state of mind with
regard to attachment will not only be a critical factor in both the development
of the alliance, but also in the ultimate outcome of psychotherapy. The research suggests attunement, or this
contingent communication described above, accounts for about 50 percent of the
transmission of attachment status from parent to child (Siegel, 1999). You can train parents to be more attuned to
their children and this will enhance attachment security with the children and
the transmission rate is about 50 percent (Van IJzendoorn, Juffer &
Duyvesteyn, 1995). Yet the general
studies on the generational transmission of attachment consistently suggest
that the actual rate of transmission from parent to child is about 80
percent. So what accounts for this 30
percent transmission gap? It has been
suggested by these writers, that perhaps there is something about the way the
brain communicates with other brains during early development in particular
that allows for such a significant transmission rate.
We
know that securely attached adults "do" certain things with their
infants that result in attachment security in their children. This is often termed parental attunement or
sensitivity. Yet these actions do not
account for all the transmission factors.
Don't forget, early in the first three years of life, the brain is still
exponentially developing, particularly in the frontal lobes: the part of the
brain that plays an important role in attachment related capacities. Perhaps it
is something about the way our brains communicate with one another. The organization of the parent's brain
(whether secure or insecure) plays a significant part in the organization of
the developing brain of the child. You
may be thinking "this guy is getting way out there." But this type of thinking is now being
discussed in neurobiology circles.
Scientists who in the past were not interested in the brain and
interpersonal relationships are now getting very interested in this
process. So like most things in our profession,
there are more questions than answers, but it is important for therapists to
ask these questions and expand our understanding of this phenomenon. What does this mean to psychotherapy? Simply stated, the more integrated and aware
the therapist is of her/his own state of mind, the greater he/she will be able
to help his/her patients achieve integration and awareness. From an attachment point of view, the more
secure the therapists, the greater they can imbue security in their
patients. This is why I suggest that all
therapists take an attachment questionnaire and discover what their own
strengths and vulnerabilities might be with regard to attachment status.
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