The Search for the Secure Base

Attachment Theory and Psychotherapy

Jeremy Holmes

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317710981
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In recent decades, attachment theory has gained widespread interest and acceptance, although the relevance of attachment theory to clinical practice has never been clear. The Search for the Secure Base shows how attachment theory can be used therapeutically. Jeremy Holmes introduces an exciting new attachment paradigm in psychotherapy with adults, describing the principles and practice of attachment-informed therapy in a way that will be useful to beginners and experienced therapists alike. Illustrated with a wide range of clinical examples, this book will be welcomed by practitioners and trainees in psychotherapy, psychoanalysis and in many other disciplines.

Chapter 1 The psychological immune system

DOI: 10.4324/9781315783260-1

An extended analogy

Modern medicine began with Jenner's discovery of vaccination against smallpox. The notion of disease agents and the body's defences against them — the science of immunology — remains a central medical paradigm, even if it is now recognized that disease also arises when defences themselves become disordered and that illness can come from within the body as well as from without.

Defence and the integrity of the individual organism are central to physical health. Attachment theory takes as its starting point a comparable need for psychological security, and sees much psychological ill-health as resulting from compromised safety systems. For Bowlby (1988), the key to psychological security is the attachment bond. The vulnerable newborn infant on the ancestral savannah needed to ensure proximity to care-givers if he was to be safe from predation. The mother-infant attachment responses (i.e. distress calls and proximity-seeking) keep him safe from macro-predation and help regulate his emotional states, just as the antibody-rich colostrum she provides keeps micro-organisms at bay.

For Winnicott (1965), famously, ‘there is no such thing as an infant, only mother and infant together’. Our physical and psychological security depends utterly on our connections with other people. To paraphrase Auden (1962), we must attach to one another or die. What has changed is that threat comes now not so much from competing species as from our own kind — the Stranger — and, as the idea of the Oedipus complex encapsulates so clearly, from the fact that those we love are also potential competitors and rivals. Relational competence in adult life starts from attachment patterns in childhood. In Chapter 3, I look in detail at how stress and trauma in childhood have long-term effects on an adult's relational competence, including ability to parent — a finding that applies to primates generally and not just to our own species (Rosenblum et al. 1994). Chapter 7 shows how attachment patterns provide a psychosocial mechanism for inter-generational transmission.

Affects and their disorders are central to many psychological illnesses and each can be seen in terms of attachment. The psychological immune system is mediated via affect. Our feelings alert us to whether we or our loved ones are safe or in danger. As Bowlby (1988) remarked, falling in love essentially means the formation of an attachment bond, whether between two adults or between parent and child. Sadness and sometimes depression result if an attachment bond is severed, anger and anxiety if it is under threat. Mania is a triumphant and delusional sense that attachment bonds can be dispensed with altogether or effortlessly formed. Excessive fears of attack underlie many phobias, and threats to status within the group play a significant part in the onset and maintenance of depression. Borderline personality disorder can be usefully seen as a disorder of the regulation of affect in which, for example, minor threats to a tenuous attachment bond are experienced as devastating and disequilibrating.

Self-esteem and security are intimately linked. We feel good about ourselves to the extent that we feel part of a network of family and friends and valued within that network. With the backing of such a group we feel we ‘cannot fail’. As we go about our business — which is, for the most part, relational — we are constantly appraising situations and our part within them. The capacity to negotiate and think about relationships — whether affiliative or aversive — increases the chances of maintaining individuals’ integrity and security and of optimizing their ‘resource-holding potential’ (Gilbert 1997). But just as the immune system may react excessively to threat in allergic conditions like asthma, or against the self in autoimmune diseases, so this appraisal mechanism may be faulty, especially if attachment bonds are weak. Negative thoughts, such as thinking of potential dangers to the self in new situations, are necessary if we are to evaluate possible threats from those we encounter. Like the phagocytosis of potentially cancerous cells by lymphocytes, these fears are normally disposed of by the ‘psychological immune system’ and banished to unconsciousness. If we have good self-esteem, based on secure attachment, we know we will be all right. But without a secure base, they may persist. Then minor setbacks may come to look like disasters; the world becomes threatening; the mental pain associated with loss of status, rather than acting as a spur to the formation of new bonds, may gain a life of its own and feel overwhelming.

A key concept in immunology is that of self-other recognition and its breakdown in disease. Failure of the normal differentiation of self and other is central to psychotic illness. In paranoia, sufferers may attribute to reality malevolent intentions that properly belong to the self. In schizophrenia, the normal labelling system by which we distinguish our own thoughts and feelings from external perceptions is compromised. As a result, sufferers feel naked and exposed — defenceless — and may react with extreme terror, withdrawal or occasionally violent counter-attack.

In autoimmune disorders, sufferers attack their own tissues as though they were intruders. A similar process is at work in the self-denigration and intrusive unwanted thoughts of depression, which are the target of much of cognitive behaviour therapy. Excessive immune responses are seen in atopic conditions like asthma; anxiety disorders and ambivalent attachment have comparable features. Sometimes an appropriate immune response fails to a occur at all; the analogue here is with those emotionally promiscuous individuals often suffering from borderline disorders, who are unable to protect themselves from emotional abuse.

Psychoanalysis has long recognized the existence of ‘defence mechanisms’, first systematically explored and classified by Anna Freud (1936; Valliant 1993). In classical psychoanalysis, defences are both necessary — it is useful not to be aware of potentially disruptive erotic and aggressive feelings — and an encumbrance — the effort of removing such thoughts from awareness restricts and compromises loving and self-assertive possibilities. Freud's resolution of this was to argue that, ‘where id is there ego shall be’; in other words, self-knowledge is the highest good, but feelings have to be seen for what they are, not acted on. An attachment version of this would argue that understanding affect and imagination — our own and those of others’ — are essential to survival if we are to negotiate the vagaries of interpersonal life. The capacity to reflect on one's story is a feature of secure attachment in which people find a middle path between being overwhelmed with emotion in ambivalent attachment and the switched-offness of the avoidant position.

An attachment perspective on defence emphasizes the inter- rather than the intra-personal aspect. Defence mechanisms describe particular patterns of intimate relationship. A securely attached individual can draw on the support of others (via the ‘secure base’) when needed and can talk coherently and with appropriate affect about psychological pain and difficulty (Hesse 1999). If the ‘immunity’ afforded by the protective other is suboptimal, a compromise will be reached in which the individual sacrifices some aspects of psychic life in return for a modicum of security. The avoidant strategy means staying near to a protective other, but not too near for fear of rejection or aggression — here a measure of intimacy is sacrificed in which affect is ‘deactivated’ (see Mallinckrodt 2000). The ambivalent individual has been subjected to inconsistent responses when distressed, and so clings to the care-giver even when no danger is present. Here there is a ‘hyperactivation’ of attachment responses and exploration and autonomy are jettisoned in return for security.

Disorganized attachments are associated with traumatic care-giving. Trauma overwhelms and disrupts the psychological immune system altogether. Disorganized responses and narratives lack any clear coherent strategy for self-protection. They are likely to arise when a care-giver is him or herself the source of threat, an extreme example of which is seen in child abuse. This sets up the typical approach-avoidance oscillation seen in borderline disorders. Less dangerous versions arise when the care-giver has herself been traumatized, and seems unable therefore to cope with infant distress. In both cases, the child may resort to extreme defensive measures to maintain some sort of internal coherence: splitting, dissociation, role reversal and excessive controllingness.

Immunology uses a variety of methods to boost or, occasionally, to dampen the individual's defence mechanisms. Therapy itself can be seen as a sort of ‘passive immunization’ in which the temporary presence of the therapist provides a measure of protection. This is especially relevant to the companionable interaction (Heard and Lake 1986) of supportive psychotherapy, and in behaviour therapy where the therapist explicitly takes the position of the secure base to help patients face their fears. A basic assumption is that self-awareness is inherently protective. The more we can use our imagination to know ourselves and others better, the more adept we are likely to be at negotiating the interpersonal world we inhabit (Humphrey 1984). A key aim of much psychotherapy, whether dynamic or cognitive, is to enhance consciousness of our own mental life — ‘narrative competence’ is a psychological equivalent of immunological competence (Holmes 1992). In the latter, around the moment of birth, the body ‘knows’ itself and so can distinguish between its own antigenic structures and those of potential pathogens. Similarly, coming to know oneself psychologically, and to distinguish between one's own feelings and those of others and, ultimately, to understand the representational nature of thinking itself (cf. Fonagy 1997), is a key to psychological survival.

Therapists aim to create some of the parameters of secure base in their dealings with patients: consistency, reliability, responsiveness, non-possessive-warmth, firm boundaries. This, it is hoped, becomes internalized as a ‘place’ in the psyche to which the patient can turn when troubled, even after therapy has come to an end. Fonagy (1991) and Meins (1999) argue that a key feature of the parents of securely attached children is their ‘mind-mindedness’ or reflexive function, the ability to empathize with their children and to see them as separate beings with feelings of their own. Mind-mindedness is also a crucial therapeutic skill.

What is the ‘mechanism’ underlying this empathic responsiveness? The immune system works on an evolutionary principle of natural selection. There is a huge variety of T-lymphocytes, each with different receptors on its surface. When a new antigen is encountered, those immune cells with complementary configurations are ‘selected’ so they proliferate and are able to mount a full-blown immune response the next time that antigen is met. Empathy depends perhaps on an analogous mechanism. As care-givers, to put ourselves in the other's shoes, we take a small fragment of our own experience and amplify it so that it fits with that of the person in our charge. In this way, our own experience as receivers of care is used when we become care-givers ourselves. Just as a tropical diseases expert needs to be immunized against the organisms she is likely to encounter, so personal therapy for therapists can be seen as an immunization process, not just to protect them and their patients from themselves, but also to extend the range of experience that therapists can then draw on in working with clients.

A final theme in this extended analogy concerns the issue of conscious and unconscious awareness of psychological immune mechanisms. Most of the time, we are no more aware of the part played by the need for security in our everyday life than we are of the workings of our lymphocytes. A 5-year-old who has hurt his knee at school may put a brave face on it until the moment when his parents come to collect him, when he will suddenly burst into tears (see Chapter 3). He has not consciously been waiting for their arrival, but the attachment response can only be activated when the secure base is present. Our security measures are biologically programmed and do not necessarily need to reach consciousness to be activated. In addition, however, there may be an element of active repression. It has been suggested that feelings of dependency and vulnerability are best kept from conscious awareness, since others are a potential source of danger, and even to be aware of weakness may be to reveal it (Nesse 1990). At times it pays us to be unaware of our vulnerability, however much our thoughts and behaviour may be influenced by it.

There is a link here with the rise of individualism and with it the expansion of therapy as a cultural presence. In traditional societies, the secure base is provided by the family and tribal group, with a hierarchy of available care-givers (Van Ijzendoorn and Sagi 1999), although, interestingly, the mother is almost always at the top of the ladder. So long as he is within the bosom of the group, the individual feels safe. Threat is generally located without and illness is attributed to jealousy and witchcraft emanating from an external source, although occasionally angry ancestors are also held responsible (i.e. from within the group).

As this traditional pattern has been superseded by the nuclear and the subnuclear family, so individualism, anomie and alienation become the themes of modern psychological life. To the extent it is not available outside, a secure base has to be constructed within the self. Psychotherapy is needed to facilitate that precarious process. The neo-Kleinian perspective on Oedipus sees gain in being able to stand outside situations — freedom of thought is the prize that compensates for loss of exclusive possession of mother (Britton 1999). Similarly, an ‘internal secure base’ (i.e. a representation or ‘working model’ of security) provides freedom of movement, both literally and emotionally, that was not perhaps available in traditional societies. But without a well-functioning psychological immune system, the path of freedom leads to chaos and failure. We accept that universal immunization is necessary for the physical health of our children. Bowlby (1988) insisted that fostering psychological security is an equally important aspect of public health. This book is motivated by a similar attempt to argue the case for psychological stability and security through psychotherapy, other treatment methods in psychiatry, and in society generally.

Chapter 2 The six domains of attachment theory

DOI: 10.4324/9781315783260-2

As a therapeutic modality, attachment theory has had a long gestation, partly because of its ambivalent relationship with psychoanalysis, which, with ethology, was one of its principal forebears. This has been as much a strength as a weakness. Half a century of research now underpins attachment approaches to therapy, and practitioners can feel confident that their interventions are based on evidence rather than unsubstantiated authority or persuasion. The aim of this chapter is to summarize the contribution of attachment ideas to psychotherapeutic practice. Implicit is the view that general or ‘non-specific’ factors are equally as important in producing good therapy outcomes as the specific features often claimed by ‘brand-named’ therapies to be the secret of their success. Patients seeking therapy are typically torn between the need for secure attachment and a terror of intimacy. Like Fisher-Mamblona's (2000) goose Feli, they fear aloneness but, at the same time, are terrified of getting close. They want to run away, but have no secure base to run to. For people to form a trusting relationship — an external secure base — and then to internalize it so that they feel secure in themselves is a developmental as well as a cognitive process and, inevitably, takes time.

Van Ijzendoorm and Sagi (1999) usefully summarize the findings of attachment theory under four main headings:

• The universality hypothesis. In all known cultures, human infants become attached to one or more specific care-givers.
• The normativity hypothesis. About 70 per cent of infants become securely attached; the remainder are insecurely attached. There are three main categories of insecure attachment: avoidant, ambivalent and disorganized. Securely attached infants settle more easily in response to stress. Thus, secure attachment is both numerically and physiologically normal.
• The sensitivity hypothesis. Attachment security is dependent on sensitive and responsive care-giving.
• The competence hypothesis. Differences in attachment security lead to differences in social competence; securely attached children are more likely to relate successfully to peers and teachers an...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Dedication
• Table Of Contents
• Illustrations
• Preface
• 1 The psychological immune system: An extended analogy
• 2 The six domains of attachment theory
• 3 Attachment theory and psychoanalysis: Finding a common language
• 4 Attachment in clinical practice
• 5 An integrative perspective on change in psychotherapy
• 6 Disorganized attachment and the ‘basic fault’
• 7 Attachment and the ‘storied self ’
• 8 Attachment and narrative in psychotherapy
• 9 Abuse, trauma and memory: An attachment perspective
• 10 Art, attachment and psychotherapy
• 11 Money and psychotherapy
• 12 Endings in psychotherapy
• Appendix: BABI – brief attachment-based therapy, a treatment modality based on attachment theory
• References
• Subject index