Attachment and Adult Clinical Practice

An Integrated Perspective on Developmental Theory, Neurobiology, and Emotional Regulation

Toni Mandelbaum

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000180145
• Edition: 1
• Topic: Psychologie
• Subtopic: Kognitive Psychologie & Kognition

This comprehensive volume addresses attachment theory's history as well as its integration with neurobiology, psychophysiology, theories of emotion, regulation theory, and mentalization theory. It explores how clinicians can connect with their clients so that they feel completely seen and heard.

Attachment theory speaks to one's biological drive to connect, to relate, and to feel heard. The author aims to achieve this by condensing the enormous and diverse literature of the field into a singular, manageable work that clinicians can use to foster these connections. The book traces the history of attachment theory and describes how neurobiological research has influenced the expansion of attachment theory, and how emotions and psychophysiology have become critical to our understanding of human attachment connections. It concludes with a detailed examination of how to apply these theories in clinical practice.

This practical book addresses attachment theory's take on integrating the mind, body, and emotion when striving toward well-being. It will be of great importance for psychotherapy students, beginning therapists, and experienced clinicians with an interest in attachment theory.

Chapter 1

Attachment theory

History

Attachment theory came into being at another point in history where the harmful consequences of loneliness and socioemotional deprivation were beginning to be understood. In the early 1900s, institutionalized infants were dying at an alarming rate. In fact, in some foundling institutions in the United States, the mortality rate reached as high as 100% (British Medical Journal, 1942). Similarly, hospitalized infants slept less, tended to lose weight, and developed more infections than infants at home. They appeared listless and unhappy. “Hospitalism,” or “a vitiated condition of the body due to long confinement in a hospital, or the morbid condition of the atmosphere of a hospital” (Spitz, 1945, p. 53), was first ascribed to malnutrition. Later, those who failed to thrive were diagnosed with nasopharyngitis, or cross-infection (British Medical Journal, 1942). Hospital policies often limited visitation by parents and it was not uncommon for parents to go a year without seeing their children because of the fear of cross-contamination (Karen, 1994). Infants were placed in small cubicles and masked nurses and doctors gingerly tiptoed around, careful not to agitate any bacteria that may have been present. Physical touch was strictly discouraged (Bakwin, 1942). Yet, even with all these safeguards, infants continued to deteriorate in their pristine cubicles and mysteriously recover upon return to their homes.

In the 1940s, researchers began exploring the reasons behind the negative effects of hospitalization on children. Bakwin, a noted pediatrician, questioned existing policy, stating “It is … reasonable to ask whether the measures used to prevent infection may not be harmful to the child” (1942, p. 31). He suggested that human contact may be critical to a baby’s well-being, novel thinking for the time. Based on this, new policies were implemented at his place of work, Bellevue Hospital in New York City, encouraging nurses and parents to interact with hospitalized children, to cuddle them, and to visit more often. Not surprisingly, the mortality rate for infants under a year decreased dramatically from 30–35% to under 10% (Van der Host & Van der Veer, 2008). The editors at the British Medical Journal concluded that “in infancy the loneliness involved in separation from home may be not only undesirable but lethal” (British Medical Journal, 1942, p. 345).

During this same time period, policies around adoption also dismissed the importance of human contact. Prevailing wisdom dictated that infants remain in institutions until their intellectual abilities and personalities unfolded. This way, adoptive parents could be assured of a fitting match, choosing a child based on what they saw. If the characters of these babies were found wanting, it was assumed that it was because they were the progeny of immoral women who had given birth out of wedlock. The fact that these institutionalized children tended to be sickly was viewed as further evidence of their inferior origins (Emde, 1992). Attachments were discouraged until a child was placed permanently in a home and people went so far as to move a child from home to home to prevent such attachments from forming (Karen, 1994). Spitz challenged these notions, suggesting that the institutionalized babies were perhaps suffering from depression due to socioemotional deprivation. Though his ideas were criticized, Spitz continued his research, documenting what he termed anaclitic depression in infants placed in foundling homes and advocating for increased maternal care, love, and interaction (Spitz, 1945; Spitz, 1946).

These researchers were among the few to challenge existing paradigms. They paved the way for the originator of attachment theory, John Bowlby (1907–1990). Bowlby overturned ideas that were held as irrefutable at the time. He was the first to systematically research and document the devastating impact of maternal separation as well as the incredible importance of a secure bond between caregiver and child.¹ He was an observer of behavior and a broad theoretician capable of thinking outside the box. Drawing from ethology, control theory, psychoanalytic and object relations theory, and Darwinian theories of evolution, he brilliantly challenged and conceptualized divergent thinking, and integrated this into a coherent model of human connection: attachment theory. His theory of love and loss explained why all humans need relationships. In fact, he stated, this need is universal. Bowlby felt that, ultimately, the attachment bond is essential to human survival.

Stages in Bowlby’s thinking

Timeline

• 1897 – Freud recanted his trauma theory
• 1907 – John Bowlby born
• 1925 – Entered Trinity College as a medical student
• 1926 – Melanie Klein emigrated from Berlin to London
• 1928 – Volunteered at Priory Gate School, a school for maladjusted children
• 1929 – Continued medical studies at University College Hospital Medical School, began analytic training, including his own analysis with Joan Riviere
• 1933 – Qualified as a doctor, began training in psychiatry
• 1936 – Appointed to the London Child Guidance Clinic as a child psychiatrist
• 1937 – Qualified as an analyst, began supervision with Melanie Klein
• 1938 – Anna Freud, along with her father Sigmund Freud, moved to London to flee persecution
• 1940 – Became an Army psychiatrist, wrote paper “Forty Four Juvenile Thieves: Their Characters and Home-Life” (published in 1944)
• 1941–1944 – The Controversial Discussions took place
• 1944 – Elected Training Secretary of the British Psycho-Analytic Society (served for three years)
• 1946 – Appointed to direct the children’s department at the Tavistock Clinic
• 1948 – Commissioned by Ronald Hargreaves, Chief of the Mental Health Section of the World Health Organization (WHO) to study the problems and needs of homeless children; Also hired James Robertson that year
• 1950 – Mary Ainsworth hired by John Bowlby
• 1951 – Wrote the WHO report, two years later published the report in paperback titled “Child Care and the Growth of Love”
• 1952 – Bowlby and Robertson presented the film A Two-Year-Old Goes to Hospital to the Royal Society of Medicine in London and to the British Psycho-Analytic Society
• 1953 – Learned of Lorenz and began the study of ethology
• 1954 – Ainsworth moved with her husband to Uganda and began the Ugandan Project
• 1956 – Ainsworth moved to Baltimore
• 1957 – Presented first (“The Nature of the Child’s Tie to His Mother”) of three papers on Attachment Theory to the British Psycho-Analytic Society
• 1958–1963 – Harlow conducted his monkey studies; Bowlby formally began formulating attachment theory
• 1963 – Ainsworth began the Baltimore Project from which she devised the Strange Situation
• 1964–1979 – Wrote trilogy Attachment (1969), Separation (1973), and Loss (1980)
• 1977 – Mary Main completed her doctorate from John Hopkins University, having studied with Mary Ainsworth, accepted a position at Berkeley and began the Berkeley Longitudinal Study
• 1978 – “Patterns of Attachment” by Ainsworth was published
• 1985 – Main, Kaplan, and Cassidy published the article “Security in Infancy, Childhood, and Adulthood: A Move to the Level of Representation”
• 1990 – Bowlby died.

Past circumstances affect present functioning and more specifically, maternal deprivation could possibly be linked to later disturbed behavior

The roots of Bowlby’s interest lie in his own life story. His thinking was shaped by his own experiences as well as by his clinical work and the research he conducted. Born in 1907 to upper-middle class British parents, Edward John Mostyn Bowlby was the fourth child of six. His was a typical upper middle-class upbringing where he saw his mother at appointed times and was raised primarily by nannies. He was not close to either parent, perceiving his mother as self-involved and distant and his father as rejecting. However, he was particularly attached to a nanny and was devastated when she left her position. At eight, Bowlby was sent to boarding school. Though Bowlby himself didn’t acknowledge the impact, it seems likely that his relationship with his parents, the loss of his favorite nanny, and his separation from home at an early age all contributed to his quest to understand the attachment bond and the impact of maternal separation.

Following high school, Bowlby continued his academic journey, studying medicine at Trinity College in Cambridge. However, soon after he began, he took a break and volunteered at two progressive schools, Bedales Junior School and Priory Gate, a school for maladjusted children. It was during this time that the seeds of attachment theory germinated (Karen, 1994; Austrian & Mandelbaum, 2008). “And when I was there, I learned everything that I have known: it was the most valuable six months in my life, really” (Van Dijken, 1998, p. 40), he said of his experience at Priory Gate School. One boy in particular affected him. This boy was expelled from public school for repeated stealing and was friendless and emotionally isolated. As it turned out, his mother had abandoned him as a baby and he had not had a consistent home since. Those at this very progressive school understood that this boy and others like him were reacting to not having had the proper care by a mother figure in their early years. This notion, unusual for the time period, greatly influenced Bowlby’s thinking. He came to understand that past circumstances affect present functioning and more specifically, maternal deprivation could possibly be linked to later disturbed behavior. His journey towards formulating attachment theory had begun.

Unresolved conflicts from a parent’s own childhood can influence his or her interactions with progeny

Once Bowlby left Priory Gate School, he completed his medical degree, trained as a psychiatrist and became a psychoanalyst. From 1936 to 1940, he worked at the London Child Guidance Clinic at Canonbury. Here, he learned a great deal from his social work colleagues Molly Lowden and Nance Fairbairn, more than he would ever learn from his analytic colleagues he has said. Whereas most analysts at that time treated children alone, Lowden and Fairbairn focused on parents’ issues as well as the presenting problem in the children. Bowlby recalled two cases that were particularly influential to his developing thinking. The first case involved a father who was very concerned about his son’s masturbating and would punish him whenever he caught him touching himself by putting him under cold water. It turned out the father himself had issues with masturbating for most of his life. In the second case, a mother was extremely punitive to her three-year-old daughter because she was envious of a new sibling. The mother soon disclosed that she had always been jealous of her younger brother. Thus, Bowlby recognized that unresolved conflicts from a parent’s own childhood can influence his or her interactions with progeny (Karen, 1994; Austrian & Mandelbaum, 2008).

Real-life experiences have a very important effect on development

In 1938, Bowlby was extremely honored when he was told he would be supervised by Melanie Klein, a prominent child psychoanalyst, as part of his psychoanalytic training. He very quickly realized he disagreed with her views completely. His first case was a young boy that was hyperactive. Bowlby noticed that the boy’s mother, who waited for the boy in the waiting room, seemed extremely anxious. Klein forbade Bowlby to meet with the mother, believing that parents were insignificant to a child’s treatment. Three months later, the boy’s mother was taken to a mental hospital because she had a breakdown. Melanie Klein was exasperated by this, because now no one could bring the child to treatment. Klein held that the environment was of far less consequence than the inner life of the child. Bowlby has said “‘and from that point onwards my mission in life was to demonstrate that real-life experiences have a very important effect on development’” (Karen, 1994, p. 46). This demonstrates another critical realization in Bowlby’s thinking. He believed that contrary to what his colleagues of the era touted, environment affects development. Because of this, he ascribed to another ideal that Lowden and Fairbairn advocated for: that families should be involved in the treatment process, something that was not typically done at that time. One could say that Bowlby was one of the first to practice family therapy. Meanwhile, Bowlby’s thinking was becoming more and more dissonant with psychoanalysts of the day.

Maternal loss or separation in early life has devastating consequences

Bowlby began to think about what exactly it is in the environment that affects development. Being a researcher at heart and frustrated by the lack of empirical testing on the part of the British analytic community, he initiated a research project at the Child Guidance Center. He observed young thieves at the center and continued to build upon what he had noticed at Priory Gate School, that something in these kids’ backgrounds was contributing to their current behavior, “‘an idea that was regarded as mad at the time’” (Karen, 1994, p. 50), he said. From 1936 to 1939, while at the London Child Guidance Clinic at Canonbury, he collected data on 44 juvenile thieves and 44 controls. What emerged from this study was remarkable. In 1944, he published his paper, the first psychoanalytic paper to include statistics. It was titled “Forty-Four Juvenile Thieves: Their Characters and Home-Life.” In it, Bowlby reported that of the 44 thieves, 40% had suffered a prolonged separation from a maternal figure in early childhood. In the control group, only 5% had suffered such a loss (Bowlby, 1944). This supported his growing belief that maternal loss or separation in early life has devastating consequences.

Bowlby set to work to explore this idea more. Because separation and loss were measurable, he initiated two studies examining these constructs. One study involved children in sanatoriums for tuberculosis who had been separated from their parents for long periods of time. The other study was commissioned by The London Advisory Committee to examine whether or not children should be visited by their parents while in hospital. He hired James Robertson, a social worker, who began to systematically observe children’s reactions to separation from parents. He noticed that typically children went through three stages of behavioral responses: protest, despair, and detachment. During the protest stage, children screamed, cried, or exhibited clinging with the threat of separation. The child is anxious and confused at this time, actively seeking the missing parent. During the next stage, despair, the child becomes disinterested in his surrounding environment and seems sad and apathetic. The child seems to be losing hope of a parent’s return and seems to be in a state of mourning. During the final phase of detachment, the child actually seems to interact more. However, he becomes nonreactive to his parent upon return (Bowlby, 1969; Karen, 1994).

In 1952, Bowlby and Robertson paired up to make a seminal movie to address maternal separation, a movie that would have an enormous impact on hospital policies and the ideas of attachment theory. It was called A Two-Year-Old Goes to Hospital. The film follows a happy but unusually controlled two-year-old girl, Laura, during her nine-day hospital stay for routine hernia surgery. Though visiting typically occurred once a week, Robertson arranged for Laura’s parents to visit her every other day. The film documents Laura as she struggles to maintain her composure during this time. She plaintively asks for her “mummy” several times and bursts into tears when she sees her parents on their first visit, begging to return home with them. She grows more and more withdrawn from her parents with each visit, but her quivering lip as she says goodbye reveals her true feelings. On her last day, she independently packs up all of her belongings and walks out of the hospital, declining to take her mother’s hand (Robertson, 1953; Karen, 1994).

The film was first shown to a large audience of nurses and doctors and, to the surprise of Bowlby and Robertson, it was not well received. It was criticized for everything from saying that Laura was not distressed at all, to claiming it slandered the medical profession, to declaring that the subject of the film did not represent the general population. Some chastised the film makers for ignoring the fact that Laura was upset by her fantasies towards her pregnant mother and not by the actual separation (Karen, 1994; Van der Horst & Van der Veer, 2008). It would take years for hospitals to implement any changes. But the stage was being set and Bowlby had some more proof of the incredibly negative effects of maternal separation.

Mother’s (or a primary caregiver’s) love is critical for mental health

As the war ended, more and more children were displaced or homeless. Because of his 44 thieves paper and because he was now known to be interested in maternal deprivation, in 1950, Bowlby was commissioned by Ronald Hargreaves, the chief of the Mental Health Section of the World Health Organization (WHO) to write a report on the psychiatric aspects of the issue of homeless children. Bowlby traveled through Europe and to the United States. Here, he met others who were also noticing that the lack or loss of a mother had grave consequences (Austrian & Mandelbaum, 2008; Van der Horst & Van der Veer, 2008). At the end of his data gathering, he wrote the monograph Maternal Care and Mental Health (1951) which was published in the book version Child Care and the Growth of Love (Bowlby, 1953). This was to make him a household name. In this monograph, he coined the term “maternal deprivation” and wrote of the devastating consequences of socioemotional deprivation. Based on his prior work and a careful analysis of the available literature in the area, he made strong recommendations on how to avoid or at least mitigate the effects of such deprivation. H...