The therapeutic alliance appears as a secure base, an internal object as a working, or representational, model of an attachment figure, reconstruction as exploring memories of the past, resistance as deep reluctance to disobey the past orders of parents not to tell or not to remember…. Whilst some traditional therapists might be described as adopting the stance ‘I know; I'll tell you’, the stance I advocate is one of ‘You know, you tell me’ … the human psyche, like human bones, is strongly inclined towards self-healing. The psychotherapist's job, like that of the orthopaedic surgeon's, is to provide the conditions in which self-healing can best take place.
(Bowlby, 1988a)
We come now to one of the main aims of this book: an attempt to describe Attachment Theory's distinctive contribution to the theory and techniques of psychotherapy in practice. Two related concepts have emerged. The first, starting from Object-Relations Theory, but going beyond it, is the idea of the core state with respect to attachment. Bowlby saw a person's attachment status as a fundamental determinant of their relationships. Whether smoothly functioning or problematic, core attachment patterns have a powerful influence on the way someone sees the world and their behaviour. When there is a secure core state, a person feels good about themselves and their capacity to be effective and pursue their projects. When the core state is insecure, defensive strategies come into play.
Bowlby's concept of defence is different from that of classical psychoanalysis (Hamilton, 1985) in that it is not primarily intra psychic – a way of reducing the internal disruption created by unmanageable feelings – but interpersonal. Secure attachment provides a positive ‘primary’ defence; ‘secondary’, pathological defences are methods of retaining proximity to rejecting or unreliable attachment figures. The two main patterns can be formulated along the lines of ‘I need to be near to my attachment figures in order to feel safe, but they may reject my advances, so I will suppress my needs both from myself and them, and remain on the emotional periphery of relationships’ (avoidant strategy), or ‘I need to be near to my attachment figures but they may fail to respond to me or intrude on me in a way I can't control, so I will cling to them and insist on their responding to and caring for me’ (ambivalent strategy). Both can be formulated in terms of dilemmas (Ryle, 1990) arising out of the need to get close and the imagined dangers of so doing: rejection, abandonment or intrusion. Both lead to inhibition of vital parts of personality functioning. In avoidance, aggression tends to be displaced or split off; in ambivalence, exploration is held back.
Such strategies are not in themselves disadvantageous, and indeed it is sometimes useful to think of both secure patterns and these ‘organised’ insecure attachment patterns as a repertoire of interpersonal strategies available if the interpersonal situation demands it. In Disorganised Attachment, however, the child tends to employ more self-defeating manoeuvres such as role reversal, and various self-soothing strategies which may entail harming oneself or others. As we have seen, these are associated with psychopathology, and prevent much greater challenges to therapists.
The second central concept to have emerged from attachment research is that of narrative. A person's core state is a condensate of the history of their primary relationships. If this history is available to them in the form of a personal narrative, then they are likely to feel secure. We have seen how ‘autobiographical competence’ (Holmes, 2010) both results from and contributes to secure attachment. The word ‘narrative’ derives from gnathos or knowing. Psychotherapy is based on the Delphic injunction (Pedder, 1982): know thyself. Making the unconscious conscious can be re-formulated as knowing and owning one's story. Narrative turns experience into a story which is temporal, coherent and has meaning. It objectifies experience so that the sufferer can see it for what it is, turning raw feeling into verbal (and sometimes visual, gestural or musical) symbols. It provides a vantage point from which to view, and where necessary modify, oneself and one's actions. It creates out of fragmentary experience an unbroken line or thread linking the present with the past and future. Narrative gives a person a sense of ownership of their past and their life.
Contemporary psychotherapy is characterised by a myriad of different schools and models of the therapeutic process.
Attachment Theory should not be seen as yet one more form of psychotherapy, but rather as highlighting features relevant to therapy generally, akin to Frank's (1986) common factors or ‘meta-model’ approach to the diversity of therapies. Frank and his successors (for example, Wampold, 2001) propose certain key elements which are shared by all therapies. These include the relationship with the therapist, which provides hope or ‘remoralisation’ – in Bowlbian terms a secure base from which to start to explore the problem; a coherent explanation for the patient's difficulties – a shared narrative; and a method for overcoming them. Holmes and Lindley (1997) saw the overall goal of psychotherapy as ‘emotional autonomy’ – the capacity to form relationships in which one feels both close and free, corresponding with Attachment Theory's picture of the secure base which facilitates exploration, but is ‘there’ in times of need.
This chapter will discuss five key themes which determine an individual's core state of attachment, and how psychotherapy may help to create secure rather than insecure/maladaptive attachments. These are: the need for and nature of a secure therapeutic base; the role of real trauma (as opposed to phantasy) in the origins of neurosis; affective processing, especially of loss and separation; the place of cognitions in therapy; and the part played by ‘companionable interaction’ between therapist and patient. The main focus will be on individual therapy, but the principles are equally applicable to group therapies, and the chapter ends with a consideration of Attachment Theory in relation to family therapy, of which Bowlby was one of the founding fathers.
Attachment and the secure base in psychotherapy
Attachment Theory predicts that when someone is faced with illness, distress, or threat they seek out an attachment figure from whom they may obtain succour. Once security is established, attachment behaviour is assuaged, and they can begin to explore. If the distress is psychological, the exploration will be of the situation which has caused the upset and the feelings it has aroused. This would be a simple account of many episodes of brief counselling, and of psychotherapy generally were it not for the question of the nature of the secure base.
The establishment of a base depends on the interaction between help-seeker and help-giver. The very fact that someone seeks psychotherapeutic help implies that they may have had difficulty in establishing such a relationship in the past. The patient brings into therapy all the failures and suspicions and losses he has experienced through his life. The defensive forms of insecure attachment – avoidance, ambivalence, disorganisation – will be brought into play in relation to the therapist. There will be a struggle between these habitual patterns, and the skill of the therapist in providing a secure base – the capacity to be responsive and attuned to the patient's feelings, to receive projections and to transmute them in such a way that the patient can face their hitherto unmanageable feelings. To the extent that this happens, the patient begins to build up an internal secure base, a capacity to deal with his own problems, and to ask for help when needed. The role of the therapist gradually attenuates until the phase of termination is reached. As therapy draws to a close, the patient is better able to form less anxiously attached relationships in the external world, and feels more secure in himself. As concrete attachment to the therapist lessens, so the qualities of self-responsiveness and self-attunement are more firmly established in the sufferer's inner world.
Freud wrote in 1913: ‘The first aim of the treatment consists in attaching … [the patient] to the treatment and to the person of the physician.’ Psychoanalysts have worried about two aspects of this attachment. First, can healthy, conscious, therapeutic attachment be distinguished from unconscious phantasy-based transferential feelings aroused in the patient by being in treatment? Second, is it the secure base of this relationship and the ‘new beginning’ (Balint, 1968) which provide the main vehicle of cure, or are interpretations and the insight they produce the crucial factors?
The therapeutic alliance and the ‘real’ relationship
Zetzel (1956) was the first to use the phrase the ‘therapeutic alliance’ to describe the non-neurotic, reality-based aspect of the therapist-patient relationship (Mackie, 1981), a term which is usually used interchangeably with that of the ‘working alliance’. Greenson (1967) sees the ‘reliable core of the working alliance in the “real”, or non-transference relationship’. By ‘real’ is meant both genuine and truthful as opposed to contrived or phoney, and also realistic and undistorted by phantasy.
In practice these distinctions are not so easy to make. The patient may well have a genuine desire to get better and to collaborate with the therapist in doing so, and yet at the same time be concealing feelings of despair and disappointment behind an idealising transference. It is certainly the therapist's task to provide a secure base for the patient: to be available regularly and reliably; to be courteous, compassionate and caring; to be able to set limits and have clear boundaries; to protect the therapy from interruptions and distractions; and not to burden the patient with his or her own difficulties and preoccupations (see Holmes, 2012b). From an attachment perspective a distressed individual automatically – unconsciously, unwittingly even – seeks security; thus the distinction between the ‘real’ and the ‘transferential’ relationship becomes less problematic. Dependency on the therapist is not seen as inherently neurotic, but as an appropriate, unavoidable and often desirable response to emotional distress.
The issue is whether the patient has formed a secure or an anxious type of attachment, and if anxious, which pattern predominates. When there has been major environmental trauma in the patient's life (for example, prolonged separation from parents, or physical or sexual abuse), the patient is unlikely to find it easy to form a secure base and may in an avoidant way approach therapy and the therapist with suspicion and reserve, and detach himself at the faintest hint of a rebuff; thus, the ‘real’ relationship may hang by a thread.
The question of whether attachment to the therapist is merely a necessary first step, paving the way for mutative transference interpretations and so on, or whether it constitutes a therapeutic element in its own right is usually understood in terms of stages of development. At the ‘two person’ stage, Balint's ‘basic fault’ patient (that is, one who is severely damaged by early environmental failure) needs a new kind of empathic experience with the therapist which only then can be internalised and provide the inner sense of security which is the precondition of autonomy. Just getting ‘into’ therapy may be problematic for such people: they may dip their toes in the water and run; or, conversely, find it hard to tolerate intervals between sessions and holiday breaks.
In less damaged ‘three person’, ‘Oedipal’ patients, attachment to the therapeutic environment can be more readily taken for granted, and the focus will be on the way the therapist is viewed and treated, rather than on the parameters of therapy itself. Kohut (1977) and Guntrip (1974) have pointed to the difference in technique required for these two types of patient, arguing that more damaged ‘borderline’ patients require greater acceptance and environmental provision. Kernberg has questioned this, claiming that limit-setting and interpretation of aggression and self-defeatingness is essential if these patients are to be helped towards adaptation to reality.
Bowlby rejected simplistic ‘stage’-based models of development, but the distinctions which attachment therapy makes between ambivalent, avoidant and disorganised patterns of insecure attachment are relevant. The disorganised pattern may represent the most disturbed patients who are threatened by too close attachment of any sort, and need a low-key supportive approach (Holmes, 2010; 2012b). The ambivalently attached need a combination of absolute reliability and firm limit-setting to help with secure attachment, combined with a push towards exploration. The avoidant group associate close contact with pain and rejection and may experience interpretations as intrusive assaults, and thus they benefit from a more flexible and friendly therapeutic relationship, with the therapist, at least in the initial stages, ‘carrying’ much of the affective aspect of the patient's inner world.
Balint's (1968) distinction between ‘ocnophils’ (those who fear emptiness, and cling to their object) and ‘philobats’ (those for whom intimacy is problematic and who prefer the spaces between objects) corresponds with the division of insecure attachment into ambivalent and avoidant patterns. Balint sees many psychoanalysts as ‘ocnophilic’, clinging to their patients with their interpretations. Like Meares and Hobson (1977) in their discussion of the ‘persecutory therapist’, he argues that attachment must be sought and accepted as a goal in its own right with more disturbed patients, while an over-interpretative approach can inhibit a patient's exploration. Indeed Bateman and Fonagy's (2009; Allen et al., 2010) Mentalisation Based Therapy (MBT) discards traditional interpretation altogether – which is often experienced by such patients as incomprehensible, shame-inducing, or denigratory – in favour of a mentalising approach. Here the patient's here-and-now capacity to think about himself and others' motives desires and projects, and how these translate into actions is the key therapeutic focus.
An important aspect of the MBT approach is a flexible approach to engagement. It is assumed that the patient will find establishing an attachment to the therapy and therapist difficult and will either flee from, or cling to therapy, or generate a degree of chaos reflective of their inner world. Attachment Theory is essentially a spatial theory in which the care-seeker is constantly monitoring and adjusting his distance from the care-giver depending on the level of perceived anxiety and the strength of the drive to explore. Balint emphasises the importance of getting the right distance from the patient, especially if words fail and the patient falls silent. The therapist must be:
‘felt to be present but must be all the time at the right distance – neither so far that the patient feels lost or abandoned, nor so close that the patient might feel encumbered and unfree – in fact at a distance that corresponds to the patient's actual need.’
(Balint, 1986)
Therapists and parents
We have seen how attachment research provides a picture of the kinds of parent-infant interaction likely to give rise to a secure base experience for the growing child. The children of parents who are responsive and attuned and see their infants as separate and sentient beings are likely to be better adjusted socially, more able to reflect on their feelings and to weave their experience into a coherent narrative. The capacity to handle loss and separation with appropriate anger, sadness and reconciliation is associated with secure attachment. These empirical findings can be compared with the Rogerian ethic arguing that effective therapists show empathy, honesty and non-possessive warmth (Truax and Carkhuff, 1967). There is thus experimental evidence that at an unconscious and non-verbal level, good therapists interact with their patients in ways comparable with those of good parents with their children. Rogerian empathy corresponds with attunement and responsiveness; honesty ensures that negative feelings, especially those connected with loss and separation based on the inevitable failures of the holding environment in therapy (therapists' illnesses, holidays, memory-lapses and so on), are dealt with openly and without prevarication; non-possessive warmth means that therapists are containing and encouraging but non-controlling (see Feeney and van Vleet, 2010).
Based on attachment research therefore we can identify three elements which go to make up the secure base phenomenon in therapy: attunement, fostering autobiographical competence, and affect regulation (Holmes, 2010).
Attunement and mis-attunement
Stern (1985) sees attunement as the basis for the emerging sense of self in the pre-verbal infant:
Tracking and attuning … permit one human to be with another in the sense of sharing likely inner experience on an almost continuous basis…. This is exactly our experience of feeling-connectedness, of being in attunement with another. It feels like an unbroken line. It seeks out the activation contour that is momentarily going on in any and every behaviour and uses that contour to keep the thread of communication unbroken.
(Stern, 1985)
For Stern, the emotionally disturbed patient is one whose early experiences lacked this sense of mirrored on-going being. There is an echo of Hamlet's farewell to Horatio when Stern compares the need for an attuning parent (or therapist) with
the continuing physiological need for an environment containing oxygen. It is a relatively silent need of which one becomes aware sharply only when it is not being met, when a harsh world compels one to draw one's breath in pain.
(Stern, 1985)
Brazelton and Cramer's (1991) synchrony, symmetry, contingency and ‘entrainment’, from which mutual play and infant autonomy begin to emerge, are likewise applicable to therapist-patient interactions. Good therapists find themselves automatically mirroring their patients' levels of speech volume and their posture. Malan's (1976) concept of ‘leapfrogging’ between patient and therapist is similar to the idea of contingency and entrainment in which parent and child hook onto each other in sequences of mutual responsiveness. This can be vividly demonstrated in videotapes of therapy, but is perhaps less easy to convey in a written account.
Sarah's ‘ums’ and ‘aahs’
Despite marriage, parenthood, a profession and a circle of good friends, Sarah had reached her fiftieth year almost without any sense of who she was or what the meaning and direction of her life should be. In her social self she played the part of a cheerful and active woman constantly fighting off feelings of depression and the wish to end her life. In therapy she returned again and again to the question, ‘Who am I?’
She had been brought up in a ‘progressive’ children's home where her parents were the proprietors. She had always felt that her mother was ‘so near and yet so far’: she could see her, but was expected, from the age of three, to fit in and share a dormitory with the other children, and was not allowed to have any kind of special relationship with her. Her father was harsh, distant, controlling, and physically and sexually abusive. She dated the origin of the split between her ‘social’ and her ‘real’ self to the age of eight, when she had naïvely tried to disclose her father's abuse but had been disbelieved, and punished by him for daring to think such ‘wickedness’. Any attunement between her inner world and the external one was fractured from then on. Peer Gynt-like, she complained that however much she peeled away the onion skin of her existence she could never find her real self.
As therapy progressed she found the ‘attuning’ sounds of the therapist – the ‘ums’ and ‘aahs’, grunts, inhalations and exhalations – immensely comforting. ‘They give me a sense that somehow you know how I feel, however much you appear distant, rejecting or uninterested (all words she had used about her parents) in your verbal comments.’ In fact, it was extremely difficult to tune into this patient, who varied between desperate attempts to draw the therapist into her pain and misery, complaining (‘Why aren't you angry about the terrible things that happened to me as a child?’), demanding (‘I need to know that you like me’), and excluding him with a self-absorbed, miserable monologue. Nevertheless, the fact that she could complain, demand and moan was, for her, in itself a considerable achievement. She dreamed of the therapist looking at her and knowing, without her having to put it into words, how she felt, and of his gently putting an arm around her in a gesture of protection.
While attunement and appropriate responsiveness are hallmarks of a secure parent-infant attachment, and by analogy, of effective therapist-patient dyads, it is equally true that mis-attunement, rupture, and disconnection are everyday features of all intimate relationships (Tronick, 2007). Contrary perhaps to Bowlby and Ainsworth's early formulations, secure relationships are by no means free from disruption, but rather ones which have built-in skills of rupture-repair. The capacity to ‘make things better’ gives participants – mother/infant, spouses, therapist/patient – a sense of agency, reparative competence and strengthens and deepens relationships (see Safran and Muran, 2000).
The above vignette could the seen as illustrating the dialectic between attunement and dysjunction that typifies most therapeutic relationships. Transferentially, the therapist is constantly pulled towards familiar, yet maladaptive, patterns of relating; these are resisted, causing partial rupture; the aim is to use the consequent states of disorientation to allow new meanings and levels of complexity to emerge.
Autobiographical competence
Winnicott (1965) described psychotherapy as ‘an extended form of history-taking’. The patient comes with a story, however tentative and disjointed, which is then worked on by therapist and patient until a more coherent and satisfying narrative emerges, with new and more complex sets of meanings, which provides an objectification and explanation of the patient's difficulties, and a vehicle or symbolisation linking inner and outer experience (Spence, 1982; Shafer, 1976). Tulving (Eagle, 1988) distinguishes between ‘semantic’ memory, which is propositional, and influences behaviour but which need not necessarily be conscious, and ‘episodic’ memory, which has a narrative structure and consists of stored chunks of remembered experience. The process of therapy can be seen as one of making ‘semantic’ memory episodic, of weaving a known and ownable narrative out of the unconscious attitudes, assumptions and affects which the patient brings to the therapy in the transference.
Thus the avoidant patient with a dismissing autobiographical style begins to allow some of the pain of separation into consciousness; the ambivalent patient with a preoccupied style can start to feel safe enough to let go of past anguish. Out of narrative comes meaning – the ‘broken line’ of insecure attachment is replaced by a sense of continuity, an inner story which enables new experience to be explored, with the confidence that it can be coped with and assimilated. Using the present tense, the next example tries to illustrate the immediacy of this process, as it emerges in the present tense, and in a single session.
Peter: stringing a story together
Peter is a man in his late fifties, in his second year of weekly therapy. He has a very strong presence: a powerful, pugnacious, a self-made man who grew up in a rough working-class neighbourhood. He is now a ship's captain, away from home for long stretches of time. His problems are depression, marital conflict and suicidal feelings which have been present for many years but which came to the surface after the birth of his youngest child.
He starts the session by talking about money. ‘I'm like my father, always worrying about money. I'm feeling good today, I've bought a car cheap, and I've got some work.’ But that means another break away from home and from therapy. A lot of therapeutic effort has gone into helping him recognise how he detaches himself from feelings of loss when he goes away. ‘I used to pride myself on not bothering to ring home or to miss them when I was away – it's only two weeks, why make a fuss?’
I take up the implication that therapy has made things more difficult for him now that he is in touch with feelings of loss and separation, rather than cutting off from them. I remind him of the misery which he described when as a child he was evacuated to the country during the war, away from the bombs but also from his mother.
‘Yes, it was terrible. After a few weeks my mother came to collect me. Did she dote on me or what? Everyone says that she did, but I just can't remember.’ He goes on to list a number of incidents from his childhood – playing truant at the age of five without his mother knowing, feeling an outsider among his playmates, learning to establish himself through fighting – ‘Who is that little boy, I just don't recognise him; is that me?’
He jokes: ‘Oh well, like my father used to say, nostalgia's like neuralgia.’
I suggest that he can't piece himself together, can't identify with the little boy that he was, because his mother wasn't there to string the episodes of his life together for him, just as I won't be there when he goes off to work next week.
He protests: ‘But I can get what I like from women,’ and gives several examples to prove his point. I acknowledge the short-term self-soothing and sense of safety which his pecadillos provide, but wonder aloud if he feels these women really know him – whether he feels I or his wife really know him – and if his mother could have let him be evacuated had she divined his sadness and fear. Perhaps it was his vitality and strength that she doted on, like the women he can get what he likes from, but never his vulnerability.
He then recounts some new history about his mother's childhood, how she was illegitimate, and how she had been only eighteen when she became pregnant by his father and they ‘had’ to get married.
I suggest that his confusion about whether or not his mother ‘doted’ on him was perhaps because she too was depressed during his infancy, just as he had become depressed after the birth of his youngest child.
There is a pause: it seems this had struck a chord: ‘Click: they always used to say what a difficult feeder I was as a baby. My father (the father who had always told this highly intelligent man what a dunce he was) had to buy special milk for me.’ He begins to weep. I wonder if his sadness was to do with the coming break. ‘No,’ he said, ‘It's gratitude – you seem to recognise what I am like.’ Perhaps, I quietly suggested, therapy was the ‘special milk’ he needed if he was to begin to feel that pain could be experienced, thought about, incorporated into an on-going narrative.
Seen from this post-Bowlbian perspective the tension between attachment and interpretation as curative factors in psychotherapy appears less problematic. The responsiveness of the therapist begins to restore the ‘broken line’ of the patient's internal world and forms the basis of a secure therapeutic base. This enables the beginnings of exploration: a narrative in which the therapist's interpretations are an attempt to modify, expand and lend coherence to the patient's story; but the narrative is not just the patient's ‘case history’. It is also the history of the therapeutic relationship itself, of the movement from what Balint (1968) calls the ‘mixed-upness’ of patient and therapist to a state of differentiation in which the patient detaches himself from the external support of the therapist and comes to rely on his own internal secure base, with a less fractured line of self.
Reality and trauma
The notion of the ‘broken line’ brings us to the question of trauma in the genesis of impaired mental health. We have seen how Bowlby's psychoanalytic education took place in an atmosphere in which, compared with the influence of phantasy in mental life, the role of external reality was seen as largely irrelevant. Bowlby found this incomprehensible and reprehensible, and in one sense his life's work could be seen as an attempt to prove Klein wrong on this point.
His model was a rather simple, common-sense one, based on Freud's early views, in which neurosis is the result of trauma, the facts or emotional implications of which have been repressed. The task of therapy is primarily to undo this repression in a non-judgemental and accepting atmosphere. This contrasts with Freud's mature views and those of contemporary psychoanalysts. Here the crucial factor is the interaction between environmental failure and the child's fantasy life. What makes trauma traumatic is, as Symington (1986) puts it, ‘when reality confirms the phantasy’. In the Oedipal situation the child feels that his attachment to the mother is threatened by her relationship with his father. He may harbour feelings of hatred towards him, and have angry outbursts at home or at school. If he is then in reality beaten by his father, or, conversely, there is no father to help him detach himself from his mother, then his internal world will be deformed, and he is likely to be mistrustful of attachment while secretly yearning for it. This will affect his subsequent relationships, which may be characterised by demandingness, violence, or detachment. If, on the other hand, his original feelings of fear and rage are acknowledged and accepted by the parents, the outcome will be favourable. A similar story can be imagined about some of the inevitable frustrations of infancy. If a mother is excessively unreliable or unpredictable, and consistently unable to accept her child's protests without retaliation, this will reinforce rather than mitigate an already split inner world. This in turn may lay the foundations for ‘borderline’ patterns of relationships in which good and evil are kept unstably apart and compromise and balance inaccessible.
Bowlby's original perception that disturbed children had in reality been traumatised and/or subjected to maladaptive developmental experience and poor parenting has been amply confirmed (for example, Critenden, 1986; Cicchetti et al., 2006). Parents do indeed abandon, neglect, physically and sexually abuse their children, and often deny that they do so and prohibit protest about the distress they have caused. Against this must be set several important qualifications. First, there are resilient children who, despite apparently appalling environmental traumata, appear to come through without major psychological damage (Rutter et al., 2009). Second, seeing people merely as victims of their circumstances, although valid at one level, downplays agency, a vital ingredient of psychological health. It also fails to comprehend the way in which pathological patterns, once internalised, are perpetuated by the sufferers themselves: the vicious circles in which mistrust breeds disappointment, avoidance invites neglect, clinging provokes rejection, depressive assumptions lead to negative experiences which confirm those assumptions.
Third, merely commiserating with a patient about the ways in which they have been damaged by their parents or by traumatic events does not in itself necessarily produce a good therapeutic outcome. For that to happen there has usually also to be some re-living (before relieving) of the emotional response to the trauma, and it is a central task of psychotherapy to provide the setting in which this affective processing can take place.
Affective processing
Bowlby's early work seemed to imply that separation, at least in the first five years of life, was inherently a bad thing, and that a major task of preventive psychiatry would be to minimise the frequency and effects of such separations. In his later work, however, there is a shift of perspective so that it is not just the facts of loss and separation, but the nature of a person's emotional response to them that matters. The way a parent handles a child's response to separation is a key factor here – whether by accepting and encouraging the expression of feelings of anger and sadness, or by sweeping them under the carpet. Bowlby saw that the task of the therapist is both to encourage appropriate emotional response to past trauma, and to be alert to the ways in which the patient is reacting to the losses and separations in therapy and to encourage discussion and ventilation of feelings about them. His views can be illustrated by his discussion of Charles Darwin's lifelong symptoms of anxiety and psychosomatic illness.
Charles Darwin: loss denied
In contrast to those who attribute Darwin's illnesses to tropical infection acquired during his 5-year circumnavigation of the globe in the Beagle, Bowlby (1990) explains his lifelong intermittent psychosomatic symptoms of palpitations, paraesthesia, exhaustion and faint-ness in terms of un-mourned loss. Darwin's mother died when he was eight. His father, a busy and irascible country doctor, whose own mother had died when he was a child, handed Charles over to the care of his older sisters, who forbade any mention of their mother's death. So powerful was the effect of this prohibition that, at the age of thirty-three, in a letter of condolence to a friend sympathising about the death of his young wife, he wrote: ‘I truly sympathise with you though never in my life having lost one near relation, I daresay I cannot imagine how severe grief such as yours must be.’
Another instance of the repression of painful affect in Darwin's life comes from his granddaughter Gwen Raverat's account of a family word game in which words are ‘stolen’ by one player from another if they can add a letter so as to create a new one. On one occasion Darwin saw someone add an ‘M’ to ‘other’ to make ‘Mother’. Darwin stared at it for some time, objecting: ‘There's no such word as M-OTHER’! Raverat's (1952) typically ‘Cambridge’ high IQ/low ‘EQ’ (Emotional intelligence), un-mentalising, explanation was that Darwin was notoriously bad at spelling!
Bowlby saw Darwin's chronic ill health as reflecting two sets of unresolved conflicts. The first was his inability to grieve, to bear the pain of the many losses in his life, starting with that of his mother, and including his wife's many pregnancies (sources of great anxiety to Darwin) and the loss of their beloved eldest daughter in 1851. The second was his ambivalent relationship with his overbearing father, whom Charles both revered and feared. Bowlby saw Darwin's hesitancy about publication of The Origin of Species (it took nearly twenty years between writing the original draft and publication, spurred on eventually by competition from natural selection's co-discoverer, Alfred Wallace) as reflecting this compliance and defiance in relation to authority. Bowlby's recipe for helping Darwin to overcome his difficulties would have been to ‘recognise and gradually counteract the powerful influence… of the strongly entrenched Darwin[ian] tradition that the best way of dealing with painful thoughts is to dismiss them from your mind and, if possible, forget them altogether’. Thus does Bowlby recruit Freud to help overcome the English Gentleman's stiff upper lip.
Bowlby and Winnicott: to commiserate or not?
We might here to compare Bowlby's ideas with those of Winnicott. Winnicott opposes reassurance or commiseration about trauma from the analyst on the grounds that they inhibit the affective processing needed for therapy to succeed. Like Bion (1978), Winnicott sees part of the mother's role as helping the infant to deal with bad feelings through her containing and transmuting functions. If the baby feels that his protest and anger are accepted and held, then the environment does not ‘impinge’ in a traumatic way: ‘The ego-support of the maternal care enables the infant to live and develop in spite of his not yet being able to control or feel responsible for what is good and bad in the environment’ (Winnicott, 1965).
Like Bowlby (but unlike Klein), Winnicott seems to acknowledge that the environment can let the child down, but argues that the child needs to have felt that everything is under his control before he can come gradually to accept his vulnerability:
The paradox is that what is good and bad in the infant's environment is not in fact a projection, but in spite of this it is necessary…. if the infant is to develop healthily that everything shall seem to him to be a projection.
(Winnicott, 1965; my italics)
Winnicott argues for an analytic attitude in which the trauma is re-experienced in the transference, but in such a way that it comes within the area of ‘omnipotence’ rather than external impingement:
In psychoanalysis there is no trauma that is outside the individual's omnipotence…. The patient is not helped if the analyst says ‘your mother was not good enough…’ Changes come in an analysis when the traumatic factors enter the psychoanalytic material in the patient's own way, and within the patient's omnipotence.
(Winnicott, 1965)
Winnicott's phrase, ‘bringing into omnipotence’, is an example of the combination of clinical accuracy with theoretical fuzziness that Bowlby was keen to remedy in psychoanalysis. It also reflects Winnicott's ambivalence about Klein. He is straining both to be true to his clinical experience (that is, that what is good and bad in a damaged child's upbringing is not just a projection) and to remain faithful to Kleinian theory (which emphasises the ‘omnipotence’ of infantile thought, and that ‘good’ and ‘bad’ are manifestations of the splitting and projection of primitive emotions). Traumatic events overwhelm the ‘stimulus barrier’ which protect us from being overwhelmed by sensations (see Garland, 1991). Such emotions, invariably painful and frightening, lodge inside the mind (in neuroscience terms, the ‘Right Brain’, McGilchrist, 2009), but cannot be processed, narrativised, and eventually appropriately transcended. The parent or protector who might help re-work, make sense of, soothe and regulate the overwhelming feelings is absent or disabled, and indeed may be the perpetrator (see Main and Hesse, 1990). The task of therapy then is to ‘re-present’ these traumatic events – via a narrative transformation from ‘semantic’ to ‘episodic’ memory – in such a way that they can be made conscious, but within a culture of security. This process could possibly be described as ‘omnipotent’ in so far as any representation or map, including the cerebral ‘map’ of feelings, is ‘omnipotent’. Thus a grain of sand could be said omnipotently to ‘contain all heaven’. Perhaps Winnicott's ‘omnipotence’ is a way of saying that for trauma to be transcended it first needs to be reawakened – rather than merely talked about at a distance – transferentially in vivo, but now in the presence of a secure base with whom the painful feelings evoked can be felt, examined, and transmuted. Here is a Bowlbian example of such emotion recollected in (comparative) tranquillity:
The tonsillectomy
A man in his thirties entered therapy because of his feelings of depression and a failed marriage. His relationships were typically avoidant. He was always seemingly throwing away the very things that he wanted. He knew what he did not want, but not what he wanted. Whenever his career threatened to be successful he would leave his job. A similar pattern affected his relationships: the closer he became to his wife, the more likely there was to be a violent argument.
He was an only child whose father had been killed in the war, and the origins of this pattern seemed to go back to his mother, on whom he was very dependent, but whom he experienced as intrusive and interfering.
In one session in deep winter he reported that, as he sat in the waiting room waiting for his session, through the closed window he had noticed the late-arriving therapist breathing steam into the cold air. The thought struck him that the therapist might have something wrong with his lungs. Then, suddenly, a flood of memories returned. He had had a tonsillectomy when he was five – in those days this entailed a two-week stay in hospital. Visiting was restricted (normal regime in those pre-Bowlbian days), and he was only allowed to see his mother through a glass window twice a week, or this at least was how he recalled it. He remembered his fury at not being able to go home with her, throwing the toys she had left for him, shouting ‘I want my mummy…’ As the memories returned, he began to cry profusely.
His feelings for the therapist could be summarised as ‘I am angry with you for being late; you deserve to die for it; but now I'm worried that you will really die; I need and want you’. This was of course a typical shift from a paranoid–schizoid love-versus-hate position to the love-and-hate of the depressive position. But how did this come about? From a Winnicottian angle, the ‘magnetism of an identical moment’ (Holmes, 2013b) – the inaccessible (late) attachment figure seen through a glass darkly – replayed the childhood trauma of his absent father and mother, but this time in such a way that it was in the ‘arena of omnipotence’ (the ‘victim’ no longer at the mercy of traumatic impingement). With the help of the therapist all this can now be thought about talked about, soothed and laid to rest.
This session seemed to be a turning point. The patient started to move from a position of ‘I don't want’, to ‘I want’, more in touch with his wishes and desires and less plagued by feelings of negativity and hopelessness. Now that the traumatic separation had been re-experienced in the therapy, it no longer needed to be enacted via projective identification (doing to his employers and girlfriend what as a child he had felt had been done to him by his mother), but could be symbolised and so become part of his owned autobiographical narrative.
Attachment and affect regulation
Implicit in the discussion of this case is the view that a crucial aspect of attachment is the way in which the attachment figure – parent, spouse, therapist – helps regulate emotions, especially difficult and painful feelings. A brief diversion in to the theory of affect regulation is needed here. Implicit here is the view that the very fabric of social life is based on affective exchange. Stripped of emotion we are unable effectively to appraise, bond, collaborate, quarrel, and repair our relationships with others. We love, hate, procreate, nurture, destroy and die under the aegis of reciprocally expressed emotions
‘Regulation’ of emotion entails the ability to ‘read’ our own and others' feelings, and to adjust them in the ever-changing affective interplay which is the essence of intimate relationships. Emotion is transmitted through facial and bodily expression and gesture, and the tone and prosody of language, as much as speech's specific content. A feature of the securely attached is the ability to openly and directly articulate emotions and to understand those of others. In insecure, and especially disorganised children this affective understanding is compromised.
Despite Bowlby's obvious interest in the emotional life of the child, affect was a concept surprisingly absent from much of Attachment Theory in the early years. By the late 1980s however (Cassidy and Kobak, 1988) attachment came to be viewed as a crucial interpersonal means of affect regulation. The distressed (fearful, threatened, unwell) child seeks out a secure base with the capacity to soothe (that is, regulate) ‘bad’ feelings, and evoke ‘good’ ones (feeling safe, held, warm, happy, cheerful, amused, interested, excited). Secure attachment is a ‘primary’ affect-regulatory strategy, and, in these early years, is inescapably dyadic. As development proceeds this co-regulation becomes internalised as the child gradually learns to cope with her own emotions, while retaining a life-long capacity to elicit co-regulation with an intimate other if feelings threaten to overwhelm. The securely attached child is more able to experience both negative and positive emotions than the insecurely attached child (Cassidy, 1994). In insecure attachment, ‘secondary’ affect regulatory strategies come into play. The avoidant child dampens down affect for the sake of maintaining proximity to a rejecting or aggressive caregiver; the resistant/ambivalent infant amplifies emotion and helplessness, hopeful of activating the caregiver's attention.
Mikulincer, Shaver and Pereg (2003) approach affect regulation from the adult attachment perspective, using self-report measures, yet arrive at similar conclusions to those studying attachment in infants and children. For example, students rated as avoidant, when exposed to threat-related words, use strategies of ‘defensive exclusion’ (Bowlby's phrase) of attachment related thoughts. Presumably, their developmental history leads them to experience attachment needs as fruitless or likely to result in further rejection and diminished security. However, psycho-physiological measures suggest that they are in fact troubled, and when exposed to cognitive overload, such thoughts and feelings threaten to break through and impair efficacy. The authors summarise their adult attachment model in a staged psychodynamic algorithm: appraisal of the threat; availability of attachment figures (or their internal representation) to help with affect regulation; if unavailable, defensive strategies – hyper-activating (corresponding to resistant attachment) or deactivating (the avoidance analogue) to compensate for lack of security.
Coan et al. (2006) used a neuroscience methodology in their examination of married couples' capacity to help buffer stress. Subjects were studied in three conditions: offering no-hand, a strangers' hand, or their spouse's hand to hold while exposed to mild electric shocks. There was a linear relationship between the quality of a marital relationship and the alleviation of arousal and diminished need for self-oriented strategies when threatened. Thus attachment relationships provide the context for affective co-regulation. Where this is problematic, therapy may be the necessary playground for acquiring these skills, which then can be generalised into the patient's outside relationships.
Therapists out of touch?
Coan et al.'s hand-holding experiment is relevant to the problem of touch in therapy. Bowlby emphasises the importance of real attachment of patient to therapist. Because attachment needs are distinct from sexual or oral drives, an attachment relationship does not necessarily betoken gratification or seduction. Attachment provides a quiet background atmosphere of security within which more dangerous feelings can be safely explored. The patient who asks to touch the therapist, to hold a hand or be hugged, is reaching out to the ‘environment mother’ who let him down or was absent in childhood. It might be legitimate in certain circumstances, with appropriate ethical safeguards (Holmes and Lindley, 1997), for the therapist to respond to such a request (Balint, 1968). In ‘Attachment and new beginning’, Pedder (1986) describes how a patient who had been separated from her mother for 6 months in infancy
buried her head in the pillow, extending her arms out loosely to either side of the pillow. Her hands moved around restlessly, reaching silently in my direction for some ten minutes. Eventually I said I thought she wanted me to take her hand, though she felt unable to say so, and then I did.
This seemed an important new beginning and she was later able to say how she had been terrified of being too demanding in asking me to hold a hand, fearing I might not trust her and might have mistaken her wish to be held as sexual. (Pedder, 1986)
Secure attachment to the therapist may be part of a ‘new beginning’ for certain patients, and some physical expression of this can be helpful; but – and here is the dilemma – the pain and anguish of separation also need to be re-experienced if the patient is to feel safe enough to form new attachments. He needs to feel that, should things go wrong, losses can be mourned, associated feelings experienced and, with the help of the therapist ‘regulated’, and that he will not be left feeling permanently bereft.
Winnicott's view that trauma needs to be brought ‘within the patient's omnipotence’ is echoed by Casement (1985) in his discussion of another case in which the patient requested physical touching. The patient had been badly burned as a child; her mother had fainted while holding her child's hand when the burn was being operated on under local anaesthetic. After initially agreeing to hand-holding, but (unlike Pedder's spontaneous response), under controlled conditions in the following session, Casement later changed his mind. This withdrawal of the offer led to fury and near-psychosis in the patient, but once this had been survived she began rapidly to improve. It seemed that the uncanny repetition in the transference of the mother's holding and then letting go of the patient, while remaining in a therapeutic context that was basically secure, had contributed to this breakthrough. Casement quotes Winnicott:
the patient used the analyst's failures, often quite small ones, perhaps manoeuvred by the patient…. The patient now hates the analyst for the failure that originally came as an environmental factor, outside the area of omnipotent control, but that is now staged in the transference. So in the end we succeed by failing – failing the patient's way. This is a long distance from the simple theory of cure by corrective experience.
(Winnicott, 1965: in Casement, 1985)
Bowlby the scientist was always parsimoniously trying to devise a ‘simple theory’ with which to explain the enormous complexity of intimate human relationships. Attachment Theory, while in general being unworried by physical contact between patient and therapist, does provide a clear rationale for exercising extreme caution in dealing with patients who have been abused in childhood, as the next example illustrates.
Safe breathing: secure base
Sarah, discussed above, was increasingly distressed as her elderly mother became ill. This coincided with her therapist having to change the time of her appointments. Following this, she started to sob and shake and over-breathe during the sessions. She brought a poem expressing her longing for a pure and childlike intimacy with her therapist. She wanted him inside her, but imperceptibly absorbing him and his influence, rather than taking him in through her mouth or genitals which she saw as sullied and contaminated. She wanted desperately to hold his hand, but he intuitively felt that this would be wrong.
When patient and therapist looked at this together they decided that this was because, as well as being the secure-base mother she so longed for, he also represented the abusive father whom she feared and loathed. Had he held her hand this would have repeated the typical abusive vicious circle in which the child clings ever more tightly to her abuser: the abuse creates a terrible anxiety which leads to attachment behaviour, which provokes more abuse and so on. By holding his hand she would have remained an object, albeit one in need of protection, whereas her greatest need was to become the subject of her own life, even though this meant ‘subjecting’ herself to intense pain and fear. In the end she soothed herself with the idea that if she could feel that she belonged for a while in his consulting room, things would be all right. Like Oliver Twist, she needed first to find a place, a location, literal and metaphorical, where she could feel attached, before she could begin to own her story.
Cognitions in therapy
We have argued that Bowlby's concept of internal working models forms a bridge between psychoanalysis, which conceives of an affectively laden and driven ‘internal world’ populated with objects and their relationships, and cognitive science, which acknowledges internal ‘models of the world’ in the form of mental representations. Psychoanalysis is concerned with affect-laden sensations which act as a distorting prism as we confront the world; cognitive therapy, meanwhile, is concerned with the perceptions and constructions which we attribute to those sensations and the erroneous assumptions which follow from them. Psychoanalysis aims to make the unconscious conscious; cognitive therapy starts from conscious thoughts but then reveals the unexamined assumptions underlying them.
Attachment provides a bridging or ‘vehicular’ language capable of translating between these two vernaculars (see Bellos, 2012) the two seemingly incompatible approaches. Bowlby sees psychological suffering as based on outdated assumptions; for example, the patient fears that he will be ignored or let down by people, or that his feelings will be dismissed or ridiculed. These are, in Bowlby's model view, fairly accurate reflections of the way the person has been treated as a child, but do not necessarily bear any relation to current reality, and can lead to poor adaptation in the form of avoidant or ambivalent relationships.
Two factors are at work in maintaining these outmoded models. The first is defensive exclusion of painful emotions which can be overcome by the affective processing advocated in the previous section. The second, related, phenomenon is the need to preserve meaning and to order incoming information from the environment in some kind of schema, however inappropriate (see Tronick and Beeghley, 2011).
Liotti (1987) sees these schemata as ‘superconscious’ (rather than unconscious) organising principles ‘which govern the conscious processes without appearing in them’, rather as computer programmes determine what appears on the screen without themselves being apparent. An important part of the task of therapy, whether cognitive or psychoanalytic, is to elicit and modify these overarching mental schemata. Given that the patient is likely to become closely attached to the therapist, it is assumed that his assumptions, preconceptions and beliefs will be brought into play in relation to the therapist, and the therapist will re-present them, as they become visible, for mutual consideration. This is Bowlby's version of the phenomenon of transference.
Always too considerate
Rose was in her fifties when she asked for help after splitting up with her second husband. She felt panicky and depressed and could not see how she would cope with being on her own. She had broken the marriage when she suddenly realised how she was compulsively deferential to her husband, and one more unreasonable request from him was the final straw.
As a child her life had changed dramatically when, at the age of seven, her father had walked out. She had been his favourite and every morning had sat on his lap while he fed her titbits. Now he had a new wife and family and she was relegated to occasional weekend visits where she slept in a cold and undecorated room, surrounded, as she saw it, by inaccessible luxury. At the same time her mother became profoundly depressed. When she recovered her mother then had numerous boyfriends, one of whom she eventually married, and who resented Rose and her sisters' presence and insisted they went to bed at five o'clock every evening. Rose soon learned to suppress her own needs and disappointments and discovered in her teens that with her charm and good looks she was able to attract powerful and successful men. These relationships provided her with an attachment of sorts and therefore a measure of the security she had lacked ever since her father's disappearance. At the same time they denied her the possibility of her emotional needs being heard or regulated, as these demanding men claimed her attention and moulded her false self. When these conflicts eventually surfaced she would break off the relationship as she had with her husband.
In her early psychotherapy sessions she announced that the last thing she wanted was any long-term commitment, merely a few sessions, to ‘sort her out’, but as the final scheduled session drew near she looked sad and tentative, insisting however that she was ‘fine’ and that everything was now going well. When challenged however, she admitted that she felt very nervous about the ending of therapy and really wanted to go on, but had ‘assumed’ that the therapist was far too busy to be bothered with her for more than a few meetings.
In this example of insecure attachment she had reproduced with the therapist the very pattern of suppression of need, compliance and role reversal (she looking after the therapist, rather than he her) that characterised her relationship with her mother. She carried over into therapy the cognitive assumption ‘I will only be loved if I look after others and please them’. This had served her well as an organiser of experience and a way of avoiding painful disappointment and frightening rage, but also deprived her of feelings of intimacy and ease.
Companionable interaction
Attachment Theory sees exploratory and attachment behaviour as reciprocal behavioural systems. The securely attached infant feels safe to explore the environment; if danger threatens, exploration is abandoned in favour of proximity-seeking to an attachment figure (Holmes, 2010). In adults, attachment can be differentiated from affiliation (Weiss, 1982; Sheldon and West, 1989). Affiliative relationships are typically with friends, siblings, best ‘mates’ (an interesting non-sexual use of the term) and comrades, and are usually based on mutual exploration of shared interests. Attachment relationships, unlike affiliation, typically provide protection from danger, including the dangers of painful feelings. Brown and Harris (1978) found that women experiencing loss who had a close confiding relationship with a spouse were protected from depression, while single mothers, even if they had close affiliative-type friendships, were not. Attachment, although a dynamic in its own right, borders and at times blends both into affiliation in one direction and sexuality in the other.
The relevance of this to psychotherapy lies in the likelihood that Heard and Lake's (1986) companionable interaction – synonymous with affiliation – is a feature of psychotherapeutic relationships, especially if prolonged, although it is rarely considered as such by theorists. Freud's early ‘training analyses’ consisted of a few walks around the Wienerwald (Roazen, 1976). A bond akin to friendship undoubtedly does develop in some psychotherapeutic relationships. The tension between the patient's need to see the therapist as a friend, and the professional parameters of the relationship may provide useful transferential material.
Contrasting opening moves
Sarah and Peter, described earlier, provide examples of this point. Sarah would start each session in a bright and breezy way, referring to the weather or to current events as she entered the consulting room. The therapist instinctively did not respond in kind – in a way that would, from the point of view of affiliation, seem almost rude. It was clear from her history that she had always managed to avoid intimacy through group living, and by making sure she was the ‘life-and-soul’ in any gathering, but always keeping her real self well hidden. Her problem was with one-to-one attachments, not affiliation.
Peter similarly would start his sessions with talk about current politics or sport, but in his case the therapist was prepared to join in, in a limited way, again without this being a thought-out strategy. Eventually, when this was discussed in therapy, what emerged was his desperate need to be liked, and his fear of being an outsider, an emotional orphan whom everyone ignored.
In Sarah's case the therapist was adjusting the therapeutic space so that she could get far enough from him to look at what was going on between them; in Peter's he was encouraging him to affiliate enough for some therapeutic interaction to begin. In most therapies there is an interplay between attachment and affiliation – which might in different terminology be seen as the interplay between transference and the working alliance. The sensitive therapist, like the good-enough parent, is always alert to the patient's need for security in the face of painful affect on the one hand, and, on the other, their wish to explore in a playful, humorous or companionable way. Sarah and Peter also exemplify the typical ambivalent and avoidant attachment patterns, and the differing therapeutic strategies they require. An ambivalent patient needs more distance; avoidant people require greater closeness. The role of the therapist is always to redress the balance.
The issue of affiliation is even more evident in group and family therapies. Affiliation to group members helps demoralised patients feel that they are of some value and importance, and to overcome isolation. Attachment in group therapy is to the group ‘matrix’ (derived from the word for mother) that holds its members securely and allows for exploration and affective processing. The family group is an affiliative as well as an attachment system, and much of the effort of systemic therapists is directed towards encouraging family members to do more things together and have more fun (while retaining their individuality and separateness). This chapter concludes with a brief consideration of Bowlby's contribution to family therapy.
Bowlby and family therapy
In all his vast output Bowlby only published one purely clinical – as opposed to theoretical or research – paper. This was ‘The study and reduction of group tensions in the family’ (Bowlby, 1949a). In it he describes his treatment at the Tavistock Clinic of a disturbed young adolescent boy who was destructive and difficult and failing to reach his potential at school. After two years of individual therapy, Bowlby felt he had reached an impasse: there was no improvement, and the boy was becoming increasingly resistant to the therapy. In desperation he took the then innovative step of arranging a joint meeting with the boy and his parents, together with a social worker. The meeting lasted two hours. The first hour consisted of a painful reiteration by the parents of their frustrations and disappointments with the boy. Bowlby countered this by suggesting that their nagging had contributed to his behaviour, but suggested that this had to be understood in the context of their own unhappy childhoods:
After 90 minutes the atmosphere changed very greatly and all three were beginning to have sympathy for the situation of the others… they found themselves co-operating in an honest endeavour to find new techniques for living together, each realising that there was a common need to do so and that the ways they had set about it in the past had defeated their object. This proved the turning point in the case.
(Bowlby, 1949a)
Here at last Bowlby was allowing himself free rein to do what he wanted, a process which began in the 1930s when he first began to chafe at the Kleinian bit. Based on Bion's ideas about group therapy he conceptualised the work needed to help a troubled family as analogous to individual therapy in which the warring parts of the personality are enabled to communicate more freely with one another and to reach compromise and accommodation. The social optimism of the period (with perhaps also a nod towards Bowlby's surgeon father) is contained within his remark that once painful and angry feelings are openly expressed,
the recognition of the basic fact that people really do want to live happily together and that this drive is working for us gives confidence, much as a knowledge of the miraculous healing powers of the body gives confidence to the surgeon.
(Bowlby, 1949a)
The paper ends with a section entitled ‘Circular reactions in family and other social groups’, which is thoroughly systemic in its outlook. Bowlby points out the vicious circles of neurosis in which ‘insecure parents create insecure children, who grow up to create an insecure society which in its turn creates more insecure parents’, and contrasts this with the virtuous circles of health and the need for ‘one great therapeutic endeavour: that of reducing tensions and of fostering understanding co-operation between groups of human beings’.
Although Bowlby did not specifically return to family therapy as a topic after this, he can be credited with having introduced the technique of seeing families together at the Tavistock Clinic, and therefore, alongside Gregory Bateson's Palo Alto group (Bateson, 1973), with being the originator of family and systemic therapy which was to become an important therapeutic mode over the ensuing decades.
Bowlby's systemic ideas were further developed by Byng-Hall (1991c), Heard (1982) and Skynner (1976). Byng-Hall illustrates the special aspect of attachment with by Schopenhauer's famous porcupine metaphor as an image for ‘too near-too far’ dilemmas within families:
A number of porcupines huddled together for warmth on a cold day in winter; but, as they began to prick one another with their quills, they were obliged to disperse. However the cold drove them together again, when just the same thing happened. At last, after many turns of huddling and dispersing, they discovered that they would be best off by remaining at little distance from one another.
(Quoted in Melges and Swartz, 1989)
Byng-Hall (1991a), from a child psychiatry perspective, sees the symptomatic patient in a dysfunctional family behaving like the buffer zone between parental porcupines: when the parents start to drift apart the child will develop symptoms which bring them together, and if they start to get dangerously close he will insinuate himself between them, thereby alleviating the imagined dangers of intimacy. Byng-Hall (1998) sees the presuppositions and assumptions which partners bring from their ‘families of origin’ into their ‘families of procreation’ in terms of ‘family scripts’ (see Waters and Waters, 2006). These are the ‘steps’ of the ‘dance’ (Minuchin, 1974), which an individual expects of himself and those close to him. The distinction made by Minuchin et al. (1978) between enmeshed and disengaged families (the former tending to occur in anorexia, the latter in behaviour disorders), can be equated in Attachment Theory terms with ambivalent and avoidant insecure attachment based on the parents' experiences as children and now reproduced with their own offspring.
As a counter-balance to Bowlby and Winnicott's emphasis on mothers, Skynner (1976) and in a different way Bretherton (2010), highlight the role of the father in family attachment patterns. In the early stages of infancy the father's job is to protect the mother–child dyad, to allow attachment to develop and for the mother's ‘primary maternal preoccupation’ (Winnicott, 1965) to flourish. Later, he needs to intrude on the intimacy of mother and child, partly in order to make his own relationship with the child and to promote attachment to himself, but also to encourage the process of healthy separation from the mother. The child needs to be able to ‘go off’ with the father, knowing that he can return to the secure base of the mother when needed. Without this ‘Oedipal’ paternal function the mother will be more likely actively to reject the child, using threats of sending him away or even suicide, which Bowlby saw as a particularly dangerous breeding ground for insecure attachment.
The family therapy perspective shows how attachment patterns perpetuate themselves through the life cycle, ‘event scripts’ being the psychological equivalent of the genome, and indeed may via epigenetics, actually have an impact as a form of ‘non-genomic inheritance’ (Meaney, 2001). The basic aims of psychotherapy – to provide a secure base, to help people express and come to terms with anger and disappointment (both of which can be seen in terms of separation protest), to achieve integration and coherence within themselves and their families – represent an attempt to intervene in this cycle. The aim is not so much to alter an individual personality as to modify a pattern of relating so that good experiences lead, by benign rather than vicious circles, to yet more good experiences, and so on. In this way a healthy social mutation will have occurred and Bowlby's vision of psychotherapy as preventive medicine will, to some degree at least, have been realised.
