Mentalizing in the Development and Treatment of Attachment Trauma

Jon G. Allen, Jon G Allen

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367101350
• eBook ISBN:
  9780429916267
• Topic: Psychology
• Subtopic: Cognitive Neuroscience & Neuropsychology
• Index: Psychology

This book brings together the latest knowledge from attachment research and neuroscience to provide a new approach to treating trauma for therapists from different professional disciplines and diverse theoretical backgrounds. The field of trauma suffers from fragmentation as brands of therapy proliferate in relation to a multiplicity of psychiatric disorders. This fragmentation calls for a fresh clinical approach to treating trauma. Pinpointing at once the problem and potential solution, the author places the experience of being psychologically alone in unbearable emotional states at the heart of trauma in attachment relationships. This trauma results from a failure of mentalizing, that is, empathic attunement to emotional distress. Psychotherapy offers an opportunity for healing by restoring mentalizing, that is, fostering psychological attunement in the context of secure attachment relationships-in the psychotherapy relationship and in other attachment relationships. The book gives a unique overview of common attachment patterns in childhood and adulthood, setting the stage for understanding attachment trauma, which is most conspicuous in maltreatment but also more subtly evident in early and repeated failures of attunement in attachment relationships.

CHAPTER ONE

Attachment in childhood

When I educate adult patients about psychiatric disorders, I use a stress-pileup model to advocate a developmental perspective. While acknowledging the role of genetic risk and temperament, the model predicates childhood adversity as promoting vulnerability to disorder in the face of adulthood stress. Yet, taking the devil’s advocate position, I preface this presentation by posing the question: Why should you care how you got into difficulty? Why not just concentrate on how to get out of it? Patients readily assert that knowing how they got into difficulty can help them get out and stay out of it. My focus on attachment and mentalizing in development and treatment provides the substance for their assertion. I add that adopting a developmental perspective fosters compassionate understanding, particularly for patients who fail to acknowledge their history of adversity and its impact on their development. Then they berate themselves (as their family members also might do): “I have so much going for me—I have no reason to be so anxious and depressed!” Such patients minimize the seriousness of their illness and the significance of their early experience.

I start this book by giving childhood its due, with my transparent bias that attachment theory and research provides the most solid foundation for psychotherapeutic treatment of trauma. The connections from development to treatment are so direct that we need no translation—merely a bit of explication that I will provide throughout.

I launch this developmental project by anchoring attachment theory in the broader domain of personality development, relying on Sidney Blatt’s (2008) influential theory of personality organization, which revolves around two fundamental developmental lines: relatedness and self-definition. Blatt’s approach to personality development dovetails beautifully with attachment theory. I find this overarching framework to be commonsensical and elegant, and it is thoroughly grounded in research. I will interweave these two perspectives throughout this book.

Attachment theory and research has a long developmental history, and awareness of this history prepares the ground for a summary of basic concepts and an overview of the ways in which attachment relationships evolve over the course of childhood. All this groundwork sets the stage for reviewing the typical patterns of secure and insecure attachment that orient the conduct of psychotherapy. I have a considerable way to go before getting to traumatic attachments, but these more ordinary patterns of secure and insecure attachment remain crucial, because traumatic attachments invariably are intermingled with and superimposed on them. Moreover, a solid understanding of secure attachment guides trauma treatment in which the attainment of greater security is paramount.

Attachment theory, like its progenitor, psychoanalysis, runs the risk of blaming mothers (as well as fathers and other caregivers) for psychological problems and psychiatric disorders. No doubt, some egregious parenting practices are blameworthy, and a focus on trauma highlights these. Nonetheless, to reiterate the point of taking a developmental perspective, my aim is compassionate understanding, and this includes compassionate understanding of the challenges parents face in the context of their developmental history and adult life circumstances. A blaming perspective is a gross oversimplification as well as a disservice to parents (Sroufe, Egeland, Carlson & Collins, 2005). Attachment develops in a partnership, and my review of secure and insecure patterns will be followed by a consideration of the child’s contribution to attachment relationships, although research suggests that child temperamental characteristics play a surprisingly limited role. In contrast, the broader family and social context influences attachment relationships in a powerful way that contributes to continuity and change in attachment patterns over the course of development. The chapter concludes with a summary of the impact of secure and insecure attachment on adjustment in childhood.

Two lines of personality development

We can understand best the profound significance of early attachment relationships by viewing them as embedded in our lifelong quest for psychological maturity. Based on decades of clinical experience and scholarly research, Blatt’s (2008) book, Polarities of Experience, identifies the need for each of us to develop and integrate two fundamental poles of experience over our lifetime, relatedness and self-definition. The self-definition pole is associated with autonomy, and I will use these terms somewhat interchangeably. Blatt summarizes:

Every person throughout life confronts two fundamental psychological developmental challenges: (a) to establish and maintain reciprocal, meaningful, and personally satisfying interpersonal relationships and (b) to establish and maintain a coherent, realistic, differentiated, integrated, essentially positive sense of self …. the articulation of these two most fundamental of psychological dimensions—the development of interpersonal relatedness and of self-definition—provides a comprehensive theoretical matrix that facilitates the integration of concepts of personality development, personality organization, psychopathology, and mechanisms of therapeutic change into a unified model. (p. 3)

In tandem with attachment theory, I will use Blatt’s framework throughout this book to help us see the forest for the trees. While we all must balance and integrate our need for relatedness and self-definition, we all tend to tilt in one direction or the other by virtue of our basic temperament and life experience. As Blatt explicates, these two poles of experience also are encouraged in different ways by different cultures, and there are conspicuous gender differences as well. Western industrialized societies place greater emphasis on self-definition, a stereotypically masculine quest. Traits consistent with an emphasis on self-definition include independence, autonomy, self-reliance, agency, competition, achievement, dominance, power, and separateness. When the emphasis on self-definition becomes defensively exaggerated to the exclusion of relatedness, maladaptive traits become evident, including envy, entitlement, narcissism, self-critical perfectionism, aggression, isolation, and alienation. Such imbalanced individuals are liable to undermine their relationships by being aloof, domineering, critical, judgmental, and hostile.

In contrast, Eastern collectivist societies place a greater emphasis on relatedness, a stereotypically feminine quest. Traits consistent with an emphasis on relatedness include dependency, cooperation, collaboration, communion, mutuality, reciprocity, altruism, empathy, affection, and intimacy. When the emphasis on relatedness becomes defensively exaggerated to the exclusion of self-definition, maladaptive traits become evident, including excessive dependency or neediness, submissiveness, passivity, self-sacrifice, and exquisite sensitivity to neglect or abandonment.

Over the course of development, we need to cultivate our capacities for relatedness and self-definition while also coordinating and integrating them: as Blatt puts it, “normal personality development involves simultaneously and mutually facilitating dialectical interaction between the two primary developmental dimensions of interpersonal relatedness and self-definition” (p. 104). These two poles are synergistic; when they are in reasonable balance, the development of each facilitates the development of the other. We come to know ourselves and define ourselves in the context of being known by others; and our sense of identity and self-worth allows us to enter into intimate relationships with others while maintaining personal boundaries and autonomy. This integration typically reaches a point of consolidation in adolescence:

Although these two developmental lines interact throughout the life cycle, they also develop relatively independently through the early developmental years until adolescence, at which time the developmental task is to integrate more mature expressions of these two developmental dimensions into the comprehensive structure Erikson called ‘self-identity.’ (p. 104)

To foreshadow the ensuing discussion, secure attachment exemplifies the achievement of a balance between relatedness and self-definition, a balance that is evident directly in using attachment as a safe haven and secure base as well as developing an internal sense of security in relating to yourself. Exaggerated reliance on one developmental pole or the other is evident in the two main patterns of insecure attachment: avoidant attachment is associated with greater concern with self-definition and autonomy to the exclusion of close relationships, whereas ambivalent attachment is associated with an exaggerated effort to maintain close relationships to the exclusion of the development of self-identity. This organizing framework for understanding development and the challenges of treatment now seems so obvious that we can overlook the brilliant clinical observations and research that led to the attainment of the framework. In the following historical sketch, I will quote liberally from the progenitors of attachment theory to underscore the contemporary relevance of their original insights.

The early development of attachment theory and research

To provide a general orientation to attachment theory, we can take four findings as fundamental (van Ijzendoorn & Sagi-Schwartz, 2008): (1) Given any opportunity, and barring extreme neurobiological impairments, all infants form attachments with one or more caregivers—including abusive and neglectful caregivers. (2) The majority of infants become securely attached. (3) Infants are more likely to be securely attached to caregivers who are sensitive and responsive to the infant’s needs. (4) Attachment security contributes positively to children’s emotional, interpersonal, and cognitive competence. These findings justify our attention to attachment when coupled with one final principle:

attachment behaviour … is characteristic of human nature throughout our lives—from the cradle to the grave. Admittedly it is usually less intense and less demanding in adolescents and adults than it is in earlier years. Yet an urgent desire for love and care is natural enough when a person is anxious and distressed. (Bowlby, 1988, p. 82, emphasis added)

It seems fitting that attachment theory and research has a father, John Bowlby, and a mother, Mary Ainsworth. In his captivating book, Becoming Attached, Robert Karen (Karen, 1998) summarized their pioneering work, the social controversies and professional politics in which it was embedded, and the subsequent evolution of attachment research. I hit some highlights here.

John Bowlby

For the past century and a half since its inception, the field of early life trauma has been fraught with controversy (Dorahy, van der Hart & Middleton, 2010). Bowlby, a psychiatrist and psychoanalyst in London, worked his way into the controversy and contributed to it. Peter Fonagy (Fonagy, 2001), also a psychoanalyst and attachment theorist, began his book integrating these two fields with the following declaration: “There is bad blood between psychoanalysis and attachment theory” (p. 1). In the ensuing years since this declaration, however, owing to Fonagy’s and others’ efforts at rapprochement (Fonagy, Gergely & Target, 2008), the bad blood has, at the very least, diminished considerably (Eagle & Wolitzky, 2009). How did it come to be in the first place? To oversimplify a long and controversial story, Bowlby differed from Freud about trauma in the context of Freud having differed from himself. The outlines of this story are well known, but the story bears repeating to underscore Bowlby’s radicalism.

Early in his career as a therapist, Freud aspired to understand the childhood origins of a wide range of symptoms in his adult patients; these symptoms included anxiety, depression, suicide attempts, painful physical sensations, and eruptions of intense emotions associated with images of hallucinatory vividness—the welter of symptoms we continue to face in conjunction with traumatic childhood relationships. Having worked with eighteen patients, Freud concluded in 1896, “At the bottom of every case … there are one or more occurrences of premature sexual experience, which occurrences belong to the earliest years of childhood but which can be reproduced through the work of psycho-analysis in spite of the intervening decades” (Freud, 1896/1962, p. 203). By 1897, he changed his mind, writing in a letter to his colleague, William Fleiss, “there was the astonishing thing that in every case … blame was laid on perverse acts by the father” but then concluded that “it was hardly credible that perverted acts against children were so general” (Freud, 1954, pp. 215–216). Decades later, in 1933 he wrote about this early turning point: “almost all my women patients told me that they had been seduced by their father. I was driven to recognize in the end that these reports were untrue and so came to understand that … symptoms are derived from phantasies and not from real occurrences” (Freud, 1964, p. 120). Freud never doubted the potentially damaging impact of early childhood trauma, or sexual abuse in particular; but he had come to doubt its sheer pervasiveness. Thus he began to interpret his patients’ symptoms as stemming from forbidden childhood sexual desires and conflicts about them rather than from actual traumatic experience. Accordingly, without denying the impact of traumatic realities, he shifted his emphasis from external reality to internal and unconscious conflicts stemming from powerful and forbidden sexual and aggressive drives.

At the start of his career in the 1930s, while training in psychoanalysis, Bowlby became interested in the relation between maternal deprivation and psychological disorders. He focused mainly on children’s experience of being separated from their mother, but he also was concerned about the impact of mothers’ emotional attitudes toward their children. Thus Bowlby’s attention to the external world of the child put him at odds with his psychoanalytic colleagues’ focus on the internal world. Consider the dramatic contrast between Bowlby’s orientation and that of his psychoanalyst, Joan Riviere, who wrote:

Psychoanalysis is … not concerned with the real world, nor with the child’s or the adult’s adaptation to the real world, not with sickness or health, nor virtue or vice. It is concerned simply and solely with the imaginings of the childish mind, the fantasied pleasures and the dreaded retributions. (quoted in Fonagy, 2001, p. 90)

The “bad blood” to which Fonagy refers also was fueled by psychoanalysts oversimplifying Bowlby’s work and vice versa (Fonagy, 2001). Integrating psychoanalysis and attachment theory remains a work in progress (Fonagy, Gergely & Target, 2008) but, in principle, there is no contradiction: traumatic events exert their influence on the basis of the way they are subjectively experienced; in understanding trauma, we always must take into account external and internal reality. Moreover, although controversy is endemic to the field of trauma (van der Kolk, 2007), we now have extensive evidence about the frequency of occurrence of various forms of childhood trauma (Koenen et al., 2008) and their adverse long-term impact (Felitti & Anda, 2010).

Throughout this book, from the review of development to the discussion of psychotherapy, I am sticking with Bowlby’s focus on separation. Notably, Bowlby was following in Freud’s (1936) footsteps. In The Problem of Anxiety, Freud asserted that the fundamental dangers in infancy—instanced by being left alone, in the dark, or with a stranger—are “all reducible to a single situation, that of feeling the loss of the loved (longed for) person” (p. 75). Freud emphasized the infant’s helplessness in the face of unmet needs: “The situation which the infant appraises as ‘danger,’ and against which it desires reassurance, is therefore one of not being gratified, of an increase of tension arising from non-gratification of its needs—a situation against which it is powerless” (p. 76, emphasis in original). Following Bowlby and in contrast to Freud, I will emphasize the sense of psychological connection as the fundamental need: the feeling of safety and meeting other needs hinges on psychological connection—mentalizing, to put it technically. Thus I will follow Bowlby’s original interest in separation with the proviso that I am compressing the time frame from prolonged separations and permanent losses to home in on repeated and brief—even momentary—separations that leave the child psychologically alone in states of extreme distress. Such states constitute the essence of trauma, explicated with increasing clarity over the course of decades by Freud, Bowlby, and Fonagy.

In the 1940s, Bowlby (1944) published the results of his first research project, which was an intensive study of the early origins of juvenile delinquency—thieving in particular. Bowlby was particularly struck by the role of prolonged separations from the mother after twelve months of age in a subgroup of delinquent children he labeled “affectionless characters.” In his words, these children were hardboiled and indifferent, unable to form loving relationships. He viewed their attitudes toward relationships as a self-protective strategy: “not to risk again the disappointment and the resulting rages and longings which wanting someone very much and not getting them involves. If we are indifferent to others or dislike them we disarm them of any power to hurt us” (p. 20). Although Bowlby emphasized prolonged separations in these individuals’ lives, these children also were subjected to various forms of maltreatment, which were evident in the histories he presented (Follan & Minnis, 2010). Given his growing expertise, the World Health Organization employed Bowlby to summarize worldwide professional knowledge about the effects of homelessness on children. As a result of this investigation, Bowlby (1951) wrote an influential monograph on maternal care and mental health, and he became recognized as a world expert on the subject.

There were many reasons for maternal deprivation, including prolonged institutionalization, lengthy hospitalizations, and children being shunted from one foster home placement to another. All these separations had the potential to be detrimental to children’s mental health. In the 1950s, Bowlby teamed up with a social worker, James Robertson, who made careful observations of the emotional impact of long-term hospitalization on very young children who were thus separated from their parents. Robertson observed a typical sequence of responses: initial protest (e.g., crying and clinging), followed by despair (e.g., listlessness and loss of hope for the parent’s return), ultimately leading to detachment (e.g., apparent indifference to the parent on reunion). Professionals generally had minimized the emotional impact of such separations, such that Bowlby and Robertson’s work met with considerable resistance. With Bowlby’s collaboration, Robertson made a poignant film port...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• ABOUT THE AUTHOR
• DEVELOPMENTS IN PSYCHOANALYSIS: SERIES FOREWORD
• PREFACE
• CHAPTER ONE Attachment in childhood
• CHAPTER TWO Attachment in adulthood
• CHAPTER THREE Holding mind in mind
• CHAPTER FOUR Attachment trauma
• CHAPTER FIVE Neurobiological connections
• CHAPTER SIX Treatment
• REFERENCES
• INDEX