The post The Applications of Attachment Theory to Psychotherapy appeared first on Confer.

Authored by Henry Strick van Linschoten

Ainsworth, M.D.S. (1964). Patterns of attachment behavior shown by the infant in interaction with his mother. Merrill-Palmer Quarterly of Behavior and Development 10:51-58.

Ainsworth, M.D.S. & Bell, S.M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development 41: 49-67.

Ainsworth, M.D.S., Bell, S.M. & Stayton, D.J. (1971). Individual differences in strange- situation behavior of one-year-olds. In H.R. Schaffer (Ed.) The Origins of Human Social Relations. New York: Academic Press.

Ainsworth, M.D.S., Blehar, M.C., Waters, E. & Wall, S. (1978). Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Erlbaum Press.

Ainsworth, M.D.S. & Wittig, B.A. (1969). Attachment and exploratory behavior of one-year- olds in a strange situation. In B.M. Foss (Ed.) Determinants of Infant Behavior (Vol. 4). London: Methuen.

Allen, J.G. (2012). Mentalizing in the Development and Treatment of Attachment Trauma. London: Karnac.

Allen, J.G., Fonagy, P. & Bateman, A.W. (2008). Mentalizing in Clinical Practice. Washington, DC: American Psychiatric Publishing.

Aron, L. (2000). Self-Reflexivity and the Therapeutic Action of Psychoanalysis. Psychoanalytic Psychology17:667-689.

Bakermans-Kranenburg, M.J. & Van IJzendoorn, M.H. (2009). The first 10,000 Adult Attachment Interviews: Distributions of adult attachment representations in clinical and non-clinical groups. Attachment & Human Development 11: 223-263.

Bateman, A.W. & Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment. Oxford: Oxford University Press.

Bateman, A.W. & Fonagy, P. (2006). Mentalization-Based Treatment for Borderline Personality Disorder: A Practical Guide. Oxford: Oxford University Press.

Bateman, A.W. & Fonagy, P. (2012). Handbook of Mentalizing in Mental Health Practice. Washington, D.C.: American Psychiatric Publishing.

Beebe, B. (2005). Forms of Intersubjectivity in Infant Research and Adult Treatment. New York: Other Press.

Beebe, B. (2012). Mothers, Infants and Young Children of September 11, 2001. London: Routledge.

Beebe, B. (2014). My Journey in Infant Research and Psychoanalysis: Microanalysis, a Social Microscope. Psychoanalytic Psychology 31:4-25.

Beebe, B. & Lachmann, F.M. (1988). The contribution of mother/infant mutual influence to the origins of self and object representations. Psychoanalytic Psychology 5: 305-330.

Beebe, B. & Lachmann, F.M. (1994). Representation and internalisation in infancy: Three principles of salience. Psychoanalytic Psychology 11: 127-165.

Beebe, B. & Lachmann, F.M. (1998). Co-Constructing Inner and Relational Processes: Self- and Mutual Regulation in Infant Research and Adult Treatment. Psychoanalytic Psychology 15:480-516.

Beebe, B. & Lachmann, F.M. (2005). Infant Research and Adult Treatment. Hillsdale, NJ: Analytic Press.

Beebe, B. & Lachmann, F.M. (2014). The Origins of Attachment: Infant Research and Adult Treatment. New York: Taylor & Francis.

Bowlby, J. (1969). Attachment and Loss. Vol. 1: Attachment. London: Random House.

Bowlby, J. (1973). Attachment and Loss. Vol. 2: Separation: Anger and Anxiety. London: Random House

Bowlby, J. (1980). Attachment and Loss Vol. 3: Loss: Sadness and Depression. London: Random House

Bowlby, J. (1982). Attachment and Loss Vol 1: Attachment 2nd ed. London: Random House.

Bowlby, J. (1988). A Secure Base. Clinical Applications of Attachment Theory. New York: Basic Books.

Cassidy, J. & Berlin, L.J. (1994). The insecure/ambivalent pattern of attachment: Theory and research. Child Development 65:971-991.

Cassidy, J. & Shaver, P.R. (Eds.) (1999). Handbook of Attachment: Theory, Research, and Clinical Applications. New York: Guilford Press.

Cassidy, J. & Shaver, P.R. (Eds.) (2008). Handbook of Attachment: Theory, Research, and Clinical Applications. 2nd ed. New York: Guilford Press.

Cozolino, L.J. (2010). The Neuroscience of Psychotherapy: Building and Rebuilding the Human Brain. New York: WW Norton.

Crittenden, P. & Landini, A. (2011). Assessing Adult Attachment. A Dynamic Maturational Approach to Discourse Analysis. New York: WW Norton.

Dennett, D. (1987). The Intentional Stance. Cambridge, MA: MIT Press.

Dozier, M. & Rutter, M. (2008). Challenges to the Development of Attachment Relationships Faced by Young Children in Foster and Adoptive Care. In J. Cassidy & P.R. Shaver, (Eds.) Handbook of Attachment: Theory, Research, and Clinical Applications. 2nd ed. New York: Guilford Press.

Dozier, M., Stovall-McClough, K.C., & Albus, K.E. (2008). Attachment and Psychopathology in Adulthood. In J. Cassidy & P.R. Shaver, (Eds.) Handbook of Attachment: Theory, Research, and Clinical Applications. 2nd ed. New York: Guilford Press.

Fonagy, P. (1991). Thinking about thinking: Some clinical and theoretical considerations in the treatment of a borderline patient. International Journal of Psycho-Analysis 72: 639- 656.

Fonagy, P. (2001). Attachment Theory and Psychoanalysis. London: Karnac.

Fonagy, P., Gergely, G., Jurist, E.L. & Target, M. (2002). Affect Regulation, Mentalization, and the Development of the Self. New York: Other Press.

Fonagy, P., Gergely, G. & Target, M. (2008). Pyschoanalytic Constructs and Attachment Theory and Research. In J. Cassidy & P.R. Shaver, (Eds.) Handbook of Attachment: Theory, Research, and Clinical Applications. 2nd ed. New York: Guilford Press.

Fonagy, P. & Target, M. (1995). Towards understanding violence: the use of the body and the role of the father. International Journal of Psycho-Analysis 76: 487-502.

Fonagy, P. & Target, M. (1996). Playing with reality: The development of psychic reality and its malfunction in borderline personalities. International Journal of Psychoanalysis 76: 39-44.

Fonagy, P. & Target, M. (1997). Attachment and reflective function: their role in self-organization. Development and Psychopathology 9(4): 679-700.

Fonagy, P. & Target, M. (2000). Playing with reality III: the persistence of dual psychic reality in borderline patients. International Journal of Psycho-Analysis 81: 853-73.

Fonagy, P. & Target, M. (2003). Psychoanalytic Theories. Perspectives from Developmental Psychology. London: Whurr Publishing.

Fonagy, P. & Target, M. (2007a). Playing with reality IV: a theory of external reality rooted in intersubjectivity. International Journal of Psycho-Analysis 88: 917-37.

Fonagy, P. & Target, M. (2007b). The rooting of the mind in the body: new links between attachment theory and psychoanalytic thought. Journal of the American Psychoanalytic Association 55: 411-56.

Fonagy, P., Steele, H., Moran, G., Steele, M. & Higgitt, A. (1991a). The capacity for understanding mental states: the reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal 13: 200-217.

Fonagy, P., Steele, H. & Steele, M. (1991b). Maternal representations of attachment during pregnancy predict the organization of infant-mother attachment at one year of age. Child Development 62: 891-905.

George, C., Kaplan, N. & Main, M. (1985). Adult Attachment Interview. Unpublished manuscript, University of California, Berkeley, CA.

Greenberg, J.R. & Mitchell, S.A. (1983). Object Relations in Psychoanalytic Psychotherapy. Cambridge, MA: Harvard University Press.

Grice, H.P. (1989). Studies in the way of words. Cambridge, MA: Harvard University Press.

Hesse, E. (2008). The Adult Attachment Interview: Protocol, Method of Analysis, and Empirical Studies. In In J. Cassidy & P.R. Shaver, (Eds.) Handbook of Attachment: Theory, Research, and Clinical Applications. 2nd ed. New York: Guilford Press.

Holmes, J. (2010a). Exploring in Security: Towards an Attachment-Informed Psychoanalytic Psychotherapy. Hove, UK: Routledge.

Holmes, J. (2010b). Integration in psychoanalytic psychotherapy – an attachment meta-perspective. Psychoanalytic Psychotherapy 24:183-201.

Holmes, J. (2014). John Bowlby and Attachment Theory. 2nd ed. Hove, UK: Routledge.

Jaffe, J., Beebe, B., Feldstein, S., Crown, C.L. & Jasnow, M.D. (2001). Rhythms of Dialogue in Infancy. Boston, MA: Blackwell.

Johnson, S.M. (2008). Couple and Family Therapy: An Attachment Perspective. In J. Cassidy & P.R. Shaver, (Eds.) Handbook of Attachment: Theory, Research, and Clinical Applications. 2nd ed. New York: Guilford Press.

Lachmann, F.M. & Beebe, B. (1996). Three principles of salience in the patient/analyst interaction. Psychoanalytic Psychology 13(1): 1-22

Lichtenberg, J., Lachmann, F.M. & Fosshage, J. (1996). The Clinical Exchange: Techniques Derived from Self and Motivational Systems. Hillsdale, NJ: Analytic Press.

Lyons-Ruth, K. & Jacobvitz, D. (2008). Attachment Disorganization: Genetic Factors, Parenting Contexts, and Developmental Transformation from Infancy to Adulthood. In J. Cassidy & P.R. Shaver, (Eds.) Handbook of Attachment: Theory, Research, and Clinical Applications. 2nd ed. New York: Guilford Press.

Main, M. (1999). Epilogue: Attachment Theory: Eighteen Points with Suggestions for Future Studies. In J.Cassidy & P.R. Shaver (Eds.) Handbook of Attachment: Theory, Research and Clinical Applications. New York: Guilford Press.

Main, M., Goldwyn, R. & Hesse, E. (2003). Adult attachment scoring and classification system. Unpublished manuscript, University of California at Berkeley, CA.

Main, M. & Solomon, J. (1986). Discovery of a new, insecure-disoranized/disoriented attachment pattern. In T.B. Brazelton & M.W. Yogman (Eds.) Affective Development in Infancy. Norwood, NJ: Ablex.

Main, M. & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M.T. Greenberg, D. Cicchetti & E.M. Cummings (Eds.) Attachment in the Preschool Years: Theory, Research, and Intervention. Chicago: University of Chicago Press.

Mikulincer, M. & Goodman, G.S. (Eds.) (2006). Dynamics of Romantic Love: Attachment, Caregiving, and Sex. New York: Guilford Press.

Mikulincer, M. & Shaver, P.R. (2007). Attachment in Adulthood: Structure, Dynamics, and Change. New York: Guilford Press.

Mitchell, S.A. (1999). Attachment Theory and the Psychoanalytic Tradition: Reflections on Human Relationally. Psychoanalytic Dialogues 9:85-107.

Mitchell, S.A. (2000). Relationality: From Attachment to Intersubjectivity. Hillsdale, NJ: Analytic Press.

Pine, F. (1981). In the beginning: Contributions to a psychoanalytic developmental psychology. International Review of Psycho-Analysis 8: 15-33.

Rutter, M. (1981). Maternal Deprivation Reassessed, 2nd ed. London: Penguin.

Safran, J.D. (2009). Interview with Lewis Aron. Psychoanalytic Psychology 26:99-116.

Schore, A. (2011). The Science of The Art of Psychotherapy. New York: WW Norton.

Schore, J.R. & Schore, A.N. (2008). Modern Attachment Theory: The Central Role of Affect Regulation in Development and Treatment. Clinical Social Work Journal 36:9-20.

Simpson, J.A. & Rholes, W.S. (Eds.) (1998). Attachment Theory and Close Relationships. New York: Guilford Press.

Slade, A. (1999). Attachment Theory and Research: Implications for the Theory and Practice of Individual Psychotherapy with Adults. In J.Cassidy & P.R. Shaver (Eds.) Handbook of Attachment: Theory, Research and Clinical Applications. New York: Guilford Press.

Slade, A. (2008). The implications of attachment theory and research for adult psychotherapy: Research and clinical perspectives. In J. Cassidy & P.R. Shaver, (Eds.) Handbook of Attachment: Theory, Research, and Clinical Applications. 2nd ed. New York: Guilford Press.

Stern, D.N. (1971). A micro-analysis of mother-infant interactions: Behavior regulating social contact between a mother and her three-and-a-half-month-old twins. Journal of the American Academy of Child Psychiatry 10: 501-517.

Stern, D.N. (1985). The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology. London: Karnac.

Stern, D.N. (2004). The Present Moment in Psychotherapy and Everyday Life. New York: WW Norton.

Stern, D.N., Sander, L.W., Nahum, J.P., Harrison, A.M., Lyons-Ruth, K., Morgan, A.C., Bruschweiler-Stern, N. & Tronick, E.Z. (1998). Non-interpretive mechanisms in psychoanalytic therapy. The ‘something more’ than interpretation. The Boston Process of Change Study Group. International Journal of Psychoanalysis79(5): 903-21.

Target, M. & Fonagy, P. (1996). Playing with reality II. The development of psychic reality from a theoretical perspective. International Journal of Psychoanalysis 77(3): 459-79.

Tronick, E.Z. (1989). Emotions and emotional communication in infants. American Psychologist 44: 112-119.

Wallin, D.J. (2007). Attachment in Psychotherapy. New York: Guilford Press.

Zeifman, D. & Hazan, C. (2008). Pair Bonds as Attachments: Developments in the Study of Couple Relationships. In J. Cassidy & P.R. Shaver, (Eds.) Handbook of Attachment: Theory, Research, and Clinical Applications. 2nd ed. New York: Guilford Press.

The post Bibliography appeared first on Confer.

Authored by Henry Strick van Linschoten

A few of the large number of references, which only touch the enormous basis of books, articles and websites devoted to attachment, are worth highlighting as next steps for a psychotherapist who, in addition to face to face professional development, would like to deepen their knowledge of attachment theory by reading.

Out of all books, the first to read is Bowlby (1988), which has lost none of its vivid readability and practical relevance. A second book that it is hard to be without, despite its size and cost, is the Handbook of Attachment, Cassidy & Shaver (2008). It may seem forbiddingly long and heavy, but the average chapter is only 25 pages, not all of them need to be read, but a number of chapters are pretty indispensable in their scope and practical utility. For adult attachment Mikulincer & Shaver (2007) is very helpful and thorough; for the clinical application of client attachment patterns, Wallin (2007) is the prime source; for mentalization, one recent overview book with clinical focus is Allen et al. (2008).

And here is a list of articles, all of which very readable, which in an easy way fit with and expand on this study aid:

• Aron (2000). Relational psychotherapy and attachment.
• Beebe (2014). Looking back on her life’s work.
• Beebe & Lachmann (1998). Self- and mutual regulation. Clinical focus.
• Fonagy & Target (2007b). Attachment theory and psychoanalysis. Mind and body.
• Holmes (2010b). Integration of psychotherapy through attachment theory.
• Mitchell (1999). Attachment theory and relationality.
• Schore & Schore (2008). Attachment theory in its clinical implications.

The post Seminal writings appeared first on Confer.

Authored by Henry Strick van Linschoten

Attachment theory sometimes seems to be everywhere, and yet it has few centres of focus, let alone cultural spaces, that explain, organise or further its popularity. The good side of that is that it shows how much the continued growth and vitality of the tradition are due to the power of its concepts, rather than to any degree of marketing, however understated. The bad side is that everyone can use the words of attachment theory – sometimes wildly incorrectly; that when there are controversies there is nobody to decide, or even to organise a debate about what is going on and how the situation should be handled.

The Bowlby Centre in London, UK is one of very few institutions substantially devoted to attachment theory, with the annual Bowlby Conferences and the internationally read Attachment Journal. Other than that it is mostly influential practitioners or researchers in attachment theory who, if they are based at a university, probably have a wider influence on the curriculum and on how others present related subjects.

This may be true of Regensburg University in Germany with the Grossmanns, Ludwig-Maximilian University in Munich with Karl-Heinz Brisch, Leiden University in the Netherlands with Marinus van IJzendoorn. In the United States there is the Washington School of Psychiatry with its Attachment and Human Development Centre, the journal Attachment and Human Development, and Mauricio Cortina. The University of Virginia still honours the memory of Mary Ainsworth, and has several scholars who are based there.

The post Cultural spaces and resources appeared first on Confer.

Authored by Henry Strick van Linschoten

There is a wide field of people with a common interest in neurobiology and attachment theory. Out of much literature, it is possible to highlight Allan Schore (2011), and for its perhaps somewhat greater readability Cozolino (2010).

Allan Schore is a psychologist with a scientific interest in neurobiology, which he has researched in depth in order to build theoretical connections between our understanding of the nervous system and relatedness. In Schore (2011), his latest book, he summarises the clinical implications of his work. He has emphasised the neurobiological underpinnings of attachment, a focus that he sees as both an evolution of attachment theory and a return to some of Freud’s early work (Schore, 2011). He also sees attachment theory as fundamentally a regulation theory based on right brain to right brain communication. Schore argues that attachment transactions allow the development of right brain systems that are involved in non conscious emotion processing and self and affect regulation. This expansion of attachment theory, like Fonagy and colleagues’ work, places affective rather than cognitive development at the centre stage. Schore sees the contribution of the therapist as mirroring the nature of early relational dynamics so that patterns of non conscious affect regulation are communicated to the therapist, also in a non conscious way, which can then assist the client in restoring more adaptive patterns of emotion regulation. These have the effect of ‘rewiring the brain’.

Although Schore’s work is complex and best read as a whole, we will summarise a few key points. Schore emphasises how the right brain has a head start during infant development and particularly how the infant’s limbic circuits, responsible for emotion processing and regulation, are shaped by “implicit” interactions between the parent and infant (Schore, 2011.). The limbic circuits have fast, non conscious, automatic categorisation and decision-making tasks that are not mediated, not until later at least, by verbal processes and conscious attention (automatic mentalizing). The development of these circuits is the outcome of right brain to right brain communication between primary caregiver and infant. If there are prolonged periods of distress and separation, these result in neural pathways that create vulnerability for relational distress later in life. The “location” of the IWMs is therefore in the right brain rather than the left brain that is responsible for verbal processing and conscious attention. The task of the therapist involves more than insight, and requires the therapist’s non conscious capacity to process the client’s states of deregulation.

See also: https://www.youtube.com/watch?v=WVuJ5KhpL34

The post The bridge between neurobiology and attachment theory appeared first on Confer.

Authored by Henry Strick van Linschoten

This is an important application of attachment theory. By making a broad assessment of the attachment style of client and therapist, it becomes easier to understand processes and even enactments in the therapeutic relationship. It is rare that clients are formally assessed for their attachment style, either by an AAI or a self-reporting instrument. Overall there are similarities between this application of attachment theory and that for couple and family therapy dynamics. Two main sources are Allen (2012) and Wallin (2007).

Client attachment patterns – Allen

There are a number of implications that arise out of understanding attachment styles for clinical practice. The therapeutic relationship is essentially asymmetrical. The client comes to a clinician for help and they often know little about the therapist. As a result the background is set for an attachment relationship to develop. In this context what the clinician does or does not do can ‘activate’ the attachment relationship, which will bring to the foreground how the client relates when they are in a help or support seeking mode. For example, emphasis on emotions rather than cognitions can activate the attachment relationship as well as the frequency of sessions and the overall length of therapy. The patient will likely be concerned with the therapist’s availability, both physical and emotional, exacerbated by separations between sessions, and emotional expression within sessions. However, because therapy involves boundaries and is an artificial relationship, Bowlby (1988) described the role of the therapist as being “analogous” to that of the mother, whereas Holmes (2010a: 57) speaks of a “quasi-secure base”. Allen (2012) stresses that the strength of the attachment relationship between therapist and client depends on the attachment history of both participants. Preoccupied clients may form intense relationships that involve dependence on the therapist; dismissing clients will treat the relationship as more of a coaching, consulting, or business relationship. Disorganised clients are likely to be very frightened and very hard to reach for long periods of time.

Consequently, an aspect of attachment informed psychotherapy is attention to the use the client is making of the therapist at any time. This can be intuited based on the client’s efforts to achieve closeness or distance. For instance, a client who is talking in a controlling way that does not easily allow for the therapist to participate in the dialogue may be understood as attempting to maintain the therapist’s attention and prevent the possibility of feeling ejected from the therapist’s mind. In contrast, a dismissing client may speak in a way that implicitly or explicitly undermines the therapist’s usefulness in order to prevent feeling dependent on the therapist. Disorganised clients may be so frightened of both intimacy and autonomy in their relationship with the therapist that they flip between the two modes of relating from session to session or within the same session. They can therefore be chaotic in the way that they affect the dyadic system they participate in .

• Secure Clients. According to Allen (2012), these individuals are more likely to seek therapy, find it easier to form a working alliance, tend to experience the therapist as available and attuned, find self-disclosure more possible, and can discuss negative feelings in order to repair alliance ruptures. Secure clients display high mentalizing skills and appear to occupy a middle ground between autonomy and intimacy.
• Dismissing clients. These clients are less likely to seek therapy, and find it harder to form a working alliance. They feel contempt for their vulnerability and are likely to feel critical towards the therapist as well as fearing criticism from the therapist. They prize autonomy, but struggle with intimacy. “Autonomous” individuals prize independence, freedom of action, privacy, and self-determination. When depressed, they are particularly sensitive to situations that they perceive as encroaching on their autonomy, mobility, or physical or mental functioning and respond with such thoughts as “I am defeated. I am incompetent. I will never be able to do what I need to do.” They are more likely to blame others for their problems although they are self-critical about their capacity to cope with situations.
• Preoccupied clients. These clients are more likely to seek therapy and engage quickly in the working alliance, but this alliance can be fragile. They prize intimacy, but can easily feel disappointed and dread the development of their own autonomy. The alliance can therefore be unstable. For example, such a client can feel intense love and need for the attachment figure, but may also be very vigilant and irritable because of fear of rejection. There is a wish to be close, and an angry determination to hurt and punish the attachment figure if they are perceived to be abandoning, in the hope that this will prevent further abandonment (Holmes, 2014).
• Disorganised Clients. These individuals can oscillate between the avoidant and ambivalent poles, showing stark switches between closeness and distance that can perhaps present in more extreme ways than the other two categories, ranging from complete detachment to terror of being abused in the therapy relationship.

Therapist attachment patterns – Wallin

Wallin (2007) has been influential in engaging with the consequences of psychotherapist attachment patterns, although references to these topics emerge in the work of other authors (e.g. Allen, 2012).

• Secure therapists. They are more likely to be flexible and respond in a sensitive way to different client presentations. They can tolerate uncertainty well and are less likely to personalise clients’ responses to them. If they are caught in an enactment they can more readily begin to think about it and encourage repair.
• Dismissing therapists. They are more likely to feel uncomfortable with expressions of intimacy, vulnerability and discomfort and less “porous” in experiencing the client’s affects, being possibly less able to empathise, although potentially more able to focus on the client’s mind. The may find dismissing clients hard and may unduly encourage dismissing clients’ autonomy at the expense of making emotional contact with them.
• Preoccupied therapists. They are more likely to feel uncomfortable with distance and rejection, and are more porous to the client’s affects, being more able to empathise, but potentially at the expense of becoming overwhelmed and focusing on their own minds instead of their clients’. They may therefore find it hard to encourage clients to take a thinking position, avoid confrontation and be over-reassuring because they may see firmness as cruelty.
• Disorganised / unresolved therapists. Wallin (2007) appears to assume that these do not exist or won’t be practising.

The relational school and attachment theory

This is an example where the body of theory and practice influenced and inspired by attachment theory is even wider and broader than attachment theory itself. Many believe that relational ways of working have been the most important overall new development in psychotherapy in the past 30 years. This is not the place to describe the basics of relational psychotherapy – in fact Confer has devoted a whole module to this subject.

Stephen Mitchell, until his untimely death one of the main forces in relational thinking, referred in many of his works to attachment theory. This is evident from the very early and prescient pages devoted to Bowlby in Greenberg & Mitchell (1983), his major article about attachment theory in Psychoanalytic Dialogues, Mitchell (1999), and to part of the subtitle of his last book, Mitchell (2000).

Lewis Aron refers several times to the importance of attachment patterns in his long interview with Safran (2009), and in a major article about new developments in psychoanalytic practice (Aron, 2000) covers similar ground to that in this study aid, placing both attachment theory and metallisation theory in a wider framework.

One of the essences of relational working is having a two-person instead of a one-person view of the therapeutic relationship. One could say that this sensibility of believing that both participants are equally important in the contact, and the importance of attainment between therapist and client, directly go back to the extreme attention paid to the mother (primary caregiver) – infant relationship in the pre-verbal period of the infant.

The post Attachment theory applied to practitioner and client appeared first on Confer.

Authored by Henry Strick van Linschoten

Another important theory strongly influenced by attachment theory is the construct of “mentalizing”, originally described by Fonagy (1991). Mentalizing refers to the capacity to understand mental states (beliefs, desires, intentions, thoughts, and feelings) in oneself and others. It was originally put forward based on clinical observation and research on the “reflective function” scale of the AAI as the potential mediating factor between attachment and mental health (Fonagy et al., 1991a; 1991b; 2002). Fonagy has stressed that being able to mentalize entails being able to adopt the “intentional” stance (Dennett, 1987): Mental states are always intentional in that they are always about something (e.g. I am angry about this or that). Jon G. Allen, an American psychologist who has embraced the concept, has added that in clinical practice mentalizing can involve mentalizing symptoms, in the sense of giving something a mental quality (Allen et al., 2008). A recent book on mentalizing is Bateman & Fonagy (2012). Although mentalizing was originally developed to explain borderline personality disorder, this book extends the concept to a number of other psychiatric presentations.

Mentalizing is thought to develop through secure attachment relationships (Fonagy et al., 2002). Mentalizing has a number of implications for the development of human beings. The capacity to develop a mind capable of understanding itself and others is not a given, but a hard-won developmental acquisition that is the outcome of secure attachment relationships. In this framework attachment is not simply seen as a behavioural system developed to ensure proximity to caregivers, but as a vehicle for ensuring that the infant will have the opportunity to develop their own mind. The purpose of mentalizing is therefore to enable the development of self-regulation and affect regulation. Paradoxically, the activation of the attachment system leading to either hyperarousal or hypoarousal is assumed to switch off mentalizing. Instead, being in a secure relationship with a caregiver allows the child to be relaxed enough to begin exploring their own and others’ minds.

Dimensions of mentalizing

Mentalizing is a multidimensional concept (Bateman & Fonagy, 2012) and overlaps with some existing, well known psychological constructs. Mentalizing is a capacity that involves a number of dimensions: Self versus other, implicit versus explicit, objective versus subjective, past versus present versus future.

• Mentalizing the self. This involves the capacity to know one’s own mental states. It is similar to mindfulness, a concept recently imported into cognitive behavioural therapy from a Buddhist context that involves paying purposeful and focused attention to the present moment. Mentalizing however is a function of the autobiographical self and refers to paying attention to the past, present and future.
• Mentalizing the other. This involves the capacity to fathom the mental states of another. It is broader than Theory of Mind, which is more focused primarily on cognitive understanding.Mentalizing implicitly versus explicitly: Implicit mentalizing is an automatic process unlike explicit mentalizing that involves effortful attention and hard work. Under situations of stress, mentalizing is more likely to become implicit, requiring the regulation of arousal toward a tolerable window in order to restore the capacity to think purposefully and intentionally (Bateman & Fonagy, 2012).
• Mentalizing in time. Mentalizing involves the capacity to embed past, present, and future understanding of oneself and others within the individual’s autobiography or, as Holmes (2010a)suggests, to developing narrative competence.

The development of mentalizing

A detailed account of the precise developmental framework for the emergence of mentalizing can be found in Fonagy et al. (2002). We will examine what occurs when mentalizing is lost and pre-mentalistic modes of functioning emerge. Fonagy and Target (1995; 1996; 1997; 2000; 2007a; 2007b; Target & Fonagy, 1996) have attempted to understand the development of psychic reality in children. They postulate an initial mode of mentalizing they refer to as “psychic equivalence”. They point to Freud’s development of the concept of psychic reality which arose out of his shift from an external, trauma-focused aetiology of the neuroses to an internal, fantasy-driven one. For the child who is younger than 18 months old, the psychic equivalence mode predominates. This mode of functioning involves the assumption that what is internal is external and vice-versa. Fantasy is therefore equated with reality, a process that can result in feelings of profound terror, as internal states are assumed to represent reality. At 18 months the child achieves the capacity to enter the “pretend mode” of mental functioning. In the pretend mode fantasy is decoupled from reality so that mental states are assumed to have no connection to reality and the child is able to pretend play. This can bring relief from the concreteness of the psychic equivalence mode. It is not until the age of three to four years that a child becomes able to begin integrating these two modes of mental functioning into a truly mentalistic stance where reality is neither “too real” nor “too unreal”.

Pre-mentalistic modes were assumed to be particularly observable in borderline clients when, due to trauma-driven insecure activation of the attachment system, their mentalizing capacities are switched off (Bateman & Fonagy, 2004; 2006; 2012). For example, if they feel mistreated by someone, they assume, in a teleological way, that this person intended to cause them harm. Self-harm and suicide attempts can be understood as efforts to bring about contingent change in the behaviour of others. The pretend mode can be observed in the “non-consequence” assumptions when violent or self-destructive behaviour is decoupled by consequences in reality. In psychic equivalence mode, the client assumes that they know what the therapist is thinking. Their internal view of reality is assumed to be the same as reality.

Part of this framework imagines how the primary caregiver has assisted in the development of mentalizing. The therapist’s task is to provide appropriate mirroring to the client’s internal states. In this way the work of mentalizing has a significant procedural component, as we have seen in the rest of this study aid. Two aspects of affect-mirroring are implicated during infant and child development (Fonagy et al., 2002). “Contingent” affect-mirroring refers to the capacity of the parent to mirror the infant’s mental states accurately in order to promote affect-regulation. If the parent is unable to do this and the child’s anxiety, for example, is responded to as if it is hostility, the child will learn that expressing vulnerability may have destructive consequences on another person later in life. This sets the scene for pretend mode function where the individual’s internal states are not rooted in reality. In contrast, the psychic equivalence mode can be amplified if the parent is unable to offer “marked” affect-mirroring. If as a response to the child’s anxiety the parent becomes anxious, then the child learns that their anxiety is infectious: what is inside appears to materialise outside. Marked affect-mirroring refers to a response that is “marked” for the child’s attention. If the parents responds in a calm, humorous or ironic way (“Aw you hurt your foot and it feels very bad”), the child internalises the parent’s response and is able to develop a “second order representation” (Fonagy et al., 2002) where they become able to represent their emotions rather than only experience them. The therapist is invited to cultivate contingent and marked ways of affect-mirroring the client in order to weaken the hold that pre-mentalistic modes can have on an individual and assist in the development of true representational thinking.

The post Mentalization theory and its roots in attachment theory appeared first on Confer.

Authored by Henry Strick van Linschoten

From the early days of Bowlby’s forensic work, attachment theory has also been applied to the severest forms of mental disorder and psychopathology, often rooted in trauma and abuse. Trauma therapy and innovations in working with (complex) trauma have extensively benefited from the perspectives of attachment theory.

Initially there may have been a thought that it was attachment security per se that had direct implications for mental health, but this was not confirmed by research. A main reason why the addition of disorganised attachment as a category to attachment patterns is so important, is that this pattern of attachment has a stronger (though still only partial) correlation with mental disorder. At least here the connection, and the scope for understanding, is much stronger than with milder forms of attachment insecurity.

Allen (2012) argues that although the specialist treatment of psychiatric disorders is often valuable, the complexity of the problems that clients present in the context of trauma, often requires a generalist approach based on an understanding of the attachment relationship. In psychological therapies in general, the client’s attachment patterns almost always from the background of therapy, even though treatment planning may not involve a direct focus on them. However, in other cases they are the agreed focus of therapeutic work, especially when the client’s current close relationships form the target of treatment.

There has been much research attempting to discover whether specific attachment patterns are linked to discreet psychiatric disorders. There has usually been an assumption that mental disorder is associated with insecure attachment patterns, but this has not been confirmed by the research that has taken place. There are only few studies that follow individuals for long periods of time (longitudinally). The majority of research has been conducted with attachment and psychiatric diagnosis established concurrently, which prevents drawing causal conclusions. It could be that (a) insecure attachment predisposes to mental disorder, (b) earlier established mental disorder affects attachment style, or (c) there is a mutually intensifying relationship between the two. Bakermans-Kranenburg & Van IJzendoorn (2009) analysed the first 10,000 AAIs reported in research literature and discovered that the results were marked by some contradictory findings, without an unequivocal connection between mental disorders and insecure attachment patterns.

Lyons-Ruth & Jacobvitz (2008), Dozier & Rutter (2008) and Dozier et al. (2008) give overviews of the importance of attachment disorganisation, the difficulty that children have to cope with extremes of deprivation, and the connections that have been found between attachment patterns and mental disorder. Pearlman & Courtois (2005) go deeper into the direct implications of attachment theory for psychotherapy with complex trauma clients.

The post The categories of attachment security and insecurity appeared first on Confer.

Authored by Henry Strick van Linschoten

Mary Main (George et al., 1985; Main et al., 2003; Main, 1999) was another pioneer of attachment theory. She was one of the central developers of the Adult Attachment Interview (AAI), a structured interview lasting over an hour. It is recorded, transcribed and the transcript analysed. It is designed to elicit attachment patterns in adulthood. A good description of the AAI, how it is conducted, and the research based on it, can be found in Hesse (2008). The premise of the AAI is that attachment styles determine the way that individuals narrate their history in the presence of another person in terms of coherence, degree of detail, contingent affect, and appropriate turn taking in dialogue. The analysis of coherence was much influenced by the work of linguistic philosopher H.P. Grice (1989). The subjects of the AAI are asked a series of questions about their early attachment-related experiences, i.e. their relationships with their parents or parenting substitutes.

When analysed according to their coherence and other characteristics, the interviewees are placed into five categories: secure; dismissing; preoccupied; unresolved / disorganised; and “cannot classify”. It is important to note that these designations are somewhat similar to, but also clearly different from the categories coded in the Strange Situation protocol. This is for the excellent scientific reason that the constructs being measured in the two protocols are clearly different, and that it was and remains a matter for research to determine their similarity or difference. Research has so far shown little correlation between attachment security measured in Strange Situations and security as measured in the AAI as an adult (Hesse, 2008). This makes it all the more important to be systematic in reviewing research about attachment theory, or thinking about clients, which categories one has in mind.

The AAI protocol can also be used is by allowing therapists who are familiar with the questions asked in the AAI and the ideas of coherence used in their scoring, to apply the same kind of thinking in reflecting on the words used by their clients in therapy.

Crittenden has developed a modified version of the AAI called Dynamic-Maturational AAI (DM-AAI). Crittenden & Landini (2011) is the major book in which they summarise their ideas built up over two decades. The authors provide a severe critique of the existing AAI, designed and developed by Main, Goldwyn and Hesse. They have reason to be disappointed with the results of 30 years of AAI, and the low correlation between AAI categories and other classifications of interest. However, their approach amounts to making a new start: their scoring method is materially different, and they have also gradually changed the questions being asked and the guidance given to interviewers. In consequence, moving to the DM-AAI would mean abandoning all conceptual and statistical continuity with the original AAI. Crittenden & Landini (2011) also want to use the DM-AAI with its extended range of subcategories to be a replacement for parts of the DSM and ICD systems. It is only if substantial numbers of researchers and research departments shift their allegiance from the AAI to the DM-AAI that the latter will have a chance to build up over a period of decades enough statistical confirmation and research articles to make this ambitious new departure credible and successful.

The AAI protocol has been found in practice too cumbersome to use for studies of people in the context of relationship problems and couple therapy. However, the wish to use the attachment categories of the AAI to classify adults has led to a development of different instruments which allow researchers to classify the people they work with or who are research subjects. These are usually more conventional psychometric questionnaires which depend on self-reporting. Quite appropriately the attachment styles established are usually given the AAI names instead of the Strange Situation names (e.g. preoccupied and dismissing, vs anxious/ambivalent and avoidant). However, most attempts to link these constructs with the same words used for the AAI categories have failed. It is probably inevitable to accept that this new class of (self-reporting) instruments measure something that is valuable, but not necessarily the same as what is observed in the AAI. A description of the efforts in this respect can be found in Crowell et al. (2008). After careful consideration they come to the conclusion that it will be necessary to consider that the AAI and self-reported tests of adolescent and adult attachment styles both measure interesting constructs, but that what they measure is not the same.

The usage of self-reporting instruments to establish adolescent and adult attachment style has grown substantially, and led to a great deal of literature. What sometimes is called “romantic attachment” seems to be clearly relevant to understanding and working with adult relationships, as illustrated in Simpson & Rholes (1998), Mikulincer & Goodman (2006), Mikulincer & Shaver (2007), Zeifman & Hazan (2008), and Mohr (2008). In this growing literature usually the relevance of Bowlby and Ainsworth’s attachment categories is amply confirmed. And just as thinking about attachment styles of therapist and client is constructive and helpful in therapy, in working with couples it turns out that an understanding and reflection on the attachment styles of the partners can be helpful in better understanding and managing those relationships. The intuition of Bowlby that infant attachment patterns, grown and developed as they may be in the course of life, remain relevant to the character and quality of (adult) relationships, continues to be confirmed.

The post Attachment theory, adolescence and adulthood; the AAIs appeared first on Confer.

Authored by Henry Strick van Linschoten

The early strands of attachment theory are based on a combination of Bowlby’s (1969) early views about attachment as a behavioural system and Ainsworth’s (Ainsworth, 1964; Ainsworth & Bell, 1970; Ainsworth et al., 1971; Ainsworth et al., 1978; Ainsworth & Wittig, 1969) inspired experiments with observing infants in an artificially constructed Strange Situation, in which they would twice be confronted with being separated from their primary caregiver, and their behavioural response was observed and scored.

Holmes defines attachment theory as “spatial” (2014:53). He proposes that the child feels good when close to the attachment figure, but sad, lonely, and anxious when far from that person. Attachment behaviours refer to any behaviour that achieves and maintain a state of proximity to a preferred person. Attachment styles are a more complex concept. There are three main attachment styles that were formulated by Mary Ainsworth in her early empirical research on the Strange Situation (Ainsworth, 1964; Ainsworth & Bell, 1970; Ainsworth et al., 1971; Ainsworth et al., 1978; Ainsworth & Wittig, 1969).

This experimental paradigm involves two brief separations between mother and her infant of about 8 to 12 months, and careful observation and analysis of the behaviour of the infant during the whole process. “Securely attached” infants display distress after separation, but approach the mother when she returns and allow themselves to be soothed. “Anxious/ambivalent” infants likewise become distressed after mother leaves and approach her when she returns, but appear clingy and unable to be comforted. “Avoidant” infants show no distress upon separation and consequently no interest in the mother when she returns. Anxious/ambivalent infants are understood to be “hyper activating” (Cassidy & Berlin, 1994) their attachment system because they perceive their caregivers as unpredictable and they have learnt that the only way to secure support is to amplify their distress. Avoidant infants, on the other hand, have no expectation that the caregiver will respond and they manage by “deactivating” or “hypo activating” the attachment system.

A fourth important category, “disorganised/disoriented” (often abbreviated to “disorganised”) infants, was added in later research: Main & Solomon (1986; 1990) wrote the first complete research reports; an overview of the history of this category since then can be found in Lyons-Ruth & Jacobvitz (2008). These children reacted in a different and more complicated way to the Strange Situation. In fact, they were often classified as “unclassifiable” in careful earlier protocols. The interpretation generally made is that their response was the result of having experienced severely abusive or neglectful caregivers and having likely been traumatised. Because they depend on the primary caregiver, the same person that is responsible for their distress, they exhibit considerable arousal when separated, but display a mixture of avoidance and approach when reunited, freezing, as well as other unusual behaviours. It is now standard, whenever possible, to extend the Strange Situation protocol with coding for all four categories.

The current state of developmental research has led to some refinement of Bowlby’s original formulations about the effects of maternal deprivation (Holmes, 2014). Holmes (2014) summarises evidence based on the report of Rutter (1981) that suggests a less direct relationship between maternal deprivation and later mental disorder or problems. Research tends to confirm that the period of six months to four years is critical in establishing the capacity to form secure attachments. It is the overall quality of the available support network for the child that determines the development of a secure base, regardless of who the primary caregiver is, the constitution of the parental couple, the presence of a single parent, the availability of grandparents, the provision of child minders and nurseries, and so forth (Rutter, 1981). Psychotherapists and psychologists sometimes assume an isomorphic relationship between the attachment to the therapist and the relationship with early figures, a view that, although widely endorsed, appears to be misleading. Holmes (2014) suggests that some of the central issues that manifest in therapy are around the child’s self-esteem and capacity to form supportive relationships. One of Bowlby’s points of emphasis is on vicious cycles that arise as a consequence of the individual’s experiences: if a person has not been given something, they are unlikely to know how to give it to their own children and are less likely to recognise relationships that can offer them what they need. Instead they are more likely to parent in a way that leads to the same deprivation they have experienced as a result of their own earlier attachment experiences. This is the foundation of interpersonal intergenerational trauma.

Implicit relational knowing is present from the first year of life, as evidenced by a number of developmental theories (Stern, 1985). Infants begin to demonstrate expectations related to their caregivers’ behaviour and are able to generalise these to other relational contexts. For example they show surprise when their expectations are violated. These expectations are the outcome of a series of tasks between infant and parent that lead to the development of an initial set of adaptive strategies. The dynamic systems perspective proposes the view that the infant’s mind operates on a self-organising principle, and unless there are external opposing forces, the infant will use all the information available to develop increasing complexity and coherence of representation. In clinical practice this is achieved when there is a moment when the interaction between client and therapist allows a new context and can be used by the client’s mind to reorganise existing patterns of implicit relational knowing. The occurrence in a moment of meeting can be detected by a sudden shift in implicit relational knowing for both participants. Stern et al. (1998:910)also use the notion of “moving along” in a manner similar to Lachmann & Beebe’s (1996) “ongoing regulation”.

The practical importance of therapist sensitivity to brief moments of heightened affective change (“moments of meeting” or “now moments”) has especially been studied by Stern and his colleagues on the Boston Change Process Study Group. This is reported in Stern et al. (1998) and Stern (2004). These processes very much partake of and are based on implicit relational knowing. This work, while using a different terminology, is clearly influenced and builds on attachment theory.

Bowlby (1969/1982; 1973; 1980) argued that the child’s attachment relationship to its primary caregivers sets down a series of interpersonal expectations that, although amenable to modification in later life, affect adolescent and adult relationship patterns to a considerable extent. Cognitive psychology from the 1970s onwards demonstrated that there are broadly speaking two types of memory, explicit or declarative (further divided into episodic and semantic) and implicit or procedural. Procedural memory is not accessible to consciousness because it is not encoded in verbal terms and is the primary type of memory until the child is at least three to four years of age. Internal Working Models (IWMs) can be understood to be procedural and non-verbal in nature, which suggests they are not amenable, at least not entirely, to insight. Instead, IWMs change through relational affective experiences with a suitably attuned other, such as a therapist.

Beebe & Lachmann (1988; 1994; 2005; 2014; Lachmann & Beebe, 1996) have elaborated a model of change that rests at the interface of relational/intersubjective psychoanalysis and attachment theory and has been articulated through research in developmental psychology. Psychotherapy allows the co-creation of healing relational contexts through the meeting of two subjectivities (an account of the relational psychoanalytic view of how this occurs can be found in Confer’s Relational Psychoanalysis study aid, included in the module of the same name). In Beebe & Lachmann’s account (1998) client and therapist regulate each other, although their contributions to the process are not equal. Self-regulation refers to an individual’s capacity to modulate their states of arousal, that is to self-comfort/self-sooth and organise one’s behaviour in predictable ways. Interactive regulation is seen as an ongoing process that is constructed moment-by-moment by the participants. Both client and therapist affect the process of interactive regulation based on their own capacities for self-regulation at the time that are specific both in style and range. Beebe & Lachmann note that concepts akin to interactive regulation have been articulated previously by both Stern (1971) and Tronick (1989). They do not see adult psychotherapy as consisting only of the process of interactive regulation, because it involves the adult’s capacity for symbolisation, and the elaboration of experience in terms of wishes, fantasies, and defences.

Lachmann & Beebe (1996) propose three principles of interactive regulation: “(O)ngoing regulations, disruption and repair of ongoing regulations, and heightened affective moments”. These forms of interactive regulation determine the management of attention, how client and therapist participate in dialogue, and how the client, and sometimes the therapist, share their feelings. The first two principles are based on second-by-second “microanalyses” of mother and infant in face-to-face interaction. In contrast, there is much less research on heightened affective moments; Lachmann & Beebe (1996) draw information from psychoanalytic insights of the second half of the 20th century to describe what these moments may look like.

Ongoing regulation involves the participants’ perceived capacity to influence and affect each other and their expectations about this capacity with this particular partner. These involve the rituals that take place in the beginning and ending of sessions, the participants’ subtle and more overt use of body language, including the rhythm, intonation, and prosody of voice. The client speaks about situations and their emotions while the therapist listens, describes, clarifies, and asks questions. Although this part of the process does not involve the use of more explicit techniques such as interpretation, it allows for the disconfirmation of interpersonal expectations of not being listened to, being rejected or misunderstood that form part of the client’s IWMs. As such they provide the basis for the internalisation of new representations of self and other. Ongoing self-regulation is therefore not secondary to interpretative or technique based work, but constitutes therapeutic action in itself.

Disruption / rupture and repair, also important concepts in relational psychotherapy, refer to violations of the participants’ expectations and the attempts involved in repairing these. The milder forms of disruption that can be repaired readily are an ordinary part of child development and ordinary therapy, although a therapist should not assume that even small disruptions can be experienced as such by this particular client. The origins of disruptions vary according to therapeutic models, but in attachment informed therapy they are considered to be the outcome of both participants’ actions. The aim of repair is to promote both verbal and non-verbal understanding for the client and to inform the therapist of the need to reconsider interventions, for example in terms of timing, pace, and tone. The outcome is also the establishment of more flexibility in the relationship, internalised by the client as a vehicle for expanding interpersonal expectations.

Heightened affective moments (Pine, 1981) refer to moments that involve a state of arousal associated with intense positive or negative affect and expressed through a range of body language resources. The outcome of the process following these can be an invaluable source for new learning as well as of (re-) traumatisation. Lachmann & Beebe (1996) offer numerous examples, such as the occurrence of silence and the use of humour.

The Strange Situation and its categorisation of attachment patterns is completely central to attachment theory. The work of Stern and colleagues, and of Beebe & Lachmann, are prime examples of later developments in ideas directly relevant to psychotherapeutic practice that were substantively influenced by attachment theory.

The post Attachment theory and the early years appeared first on Confer.