Exploring in Security

Towards an Attachment-Informed Psychoanalytic Psychotherapy

Jeremy Holmes

• Publisher: Routledge
• Year: 2009
• ISBN:
  9781135149352
• Edition: 1
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

Winner of the 2010 Goethe Award for Psychoanalytic and Psychodynamic Scholarship!

This book builds a key clinical bridge between attachment theory and psychoanalysis, deploying Holmes' unique capacity to weld empirical evidence, psychoanalytic theory and consulting room experience into a coherent and convincing whole. Starting from the theory–practice gap in psychoanalytic psychotherapy, the book demonstrates how attachment theory can help practitioners better understand what they intuitively do in the consulting room, how this benefits clients, and informs evidence-based practice.

Divided into two sections, theory and practice, Exploring in Security discusses the concept of mentalising and considers three components of effective therapy – the therapeutic relationship, meaning making and change promotion – from both attachment and psychoanalytic perspectives. The second part of the book applies attachment theory to a number of clinical situations including:

• 
  
  

• working with borderline clients
• suicide and deliberate self-harm
• sex and sexuality
• dreams
• ending therapy.

Throughout the book theoretical discussion is vividly illustrated with clinical material, personal experience and examples from literature and film, making this an accessible yet authoritative text for psychotherapy practitioners at all levels, including psychoanalysts, psychiatrists, clinical psychologists, mental health nurses and counsellors.

Part I

Principles

Chapter 1

Assuming

Any activity, whether intellectual or practical, is informed by an ideology: a set of more or less conscious underlying guiding beliefs and principles. These taken-for-granted facts and theories form the seedbed from which new ideas arise, but, if unexamined, also trammel creative thought. The aim of this preliminary chapter is to foreground this book’s basic assumptions, clearing the ground for what follows. I start with a brief orientation for those unfamiliar with attachment theory (and an update for the initiated), followed by a summary of the particular psychoanalytic perspective adopted.

A very brief history of attachment theory

Since its inception nearly half a century ago, attachment theory’s history, especially as it has developed in the UK, can be divided into three main phases (for a comprehensive account, see Cassidy and Shaver 2008). The starting point for Bowlby (in the UK) and Ainsworth (first in Uganda and then in Baltimore, USA) was the ‘obvious’ fact, somehow overlooked by psychological theorists, that individuals of whatever age, when threatened, ill, tired or vulnerable, seek proximity to a wiser, stronger ‘secure base’ for protection, and that until these attachment needs are assuaged, other motivational forces – sex, exploration, etc. – are in abeyance. In children, or severely stressed adults, physical proximity is sought. Where stress is less, or the subject is mature, vocal (e.g. cell-phone) or visual (e.g. through a photo) contact may suffice.

Ainsworth’s Strange Situation enabled researchers observing reactions to a brief separation from care-givers to classify young toddlers into two overall categories: securely and insecurely attached. The latter were then further subdivided into two main patterns, now conveniently known as the deactivating (formerly avoidant) and hyperactivating (formerly ambivalent) pattern. The new nomenclature derives from the US-based self-report strand of attachment research, studying young adults and their romantic relationships (Mikulincer and Shaver 2008). Longitudinal studies have subsequently shown that these patterns remain relatively stable through childhood and adolescence, although children can move from secure to insecure and vice versa under defined circumstances (e.g. mother becomes depressed – secure to insecure; mother’s circumstances improve or she receives psychotherapy – insecure to secure).

Phase 2 of attachment theory’s history, sometimes described as a ‘move to the level of representation’, was initiated by Mary Main and her co-workers at Berkeley, California (Main 1995). This refers to a shift from Bowlby and Ainsworth’s ethologically influenced accounts of attachment behaviours in children and their parents to Main and Solomon’s Adult Attachment Interview (AAI), which classifies adult’s verbal descriptions of their childhood experiences of attachment, loss and trauma. The AAI taps into the respondent’s narrative style, as a manifestation of how relationships are experienced, thought about, verbalised – ‘represented’ – in the subject’s mind.

In another of her inspired contributions Main and co-workers also identified a third category of insecure attachment – ‘insecure disorganised’ – which is particularly associated with high levels of stress and disturbance, both in children so classified and in their care-givers (Lyons-Ruth and Jacobvitz 2008).

Phase 3 starts around the 1990s with a series of experimental, theoretical and clinical studies associated initially with Peter Fonagy and Miriam and Howard Steele at University College London. Using the AAI, they prospectively linked parents-to-be’s ‘state of mind with respect to attachment’ with the subsequent attachment classification of their infants in the Strange Situation (Fonagy et al. 2002). Their ‘reflexive function’ subscale refers to the care-giver’s ability to ‘think about thinking’: (a) to see their own thoughts and those of their infants for what they are, not necessarily accurate representations of reality, and (b) to comprehend others as autonomous beings whose emotional arousal is motivated by desires, wishes and projects, reflecting an ‘inner’ sentient Self. Parents’ capacity to reflect on their own and their infant’s mental states was strongly linked to security of attachment in their offspring. Attachment security or insecurity is thereby transmitted down the generations.

Experimentally measurable ‘reflexive function’ then formed the core of what, by the turn of the century, had become the guiding theoretical concept of this group – ‘mentalising’ (Allen and Fonagy 2006; Allen et al. 2008). Mentalising refers to the ability to reflect on thinking and thereby to grasp the perspectival nature of thought, and the experiential ground from which it arises. Portmanteau definitions of mentalising include: ‘the ability to see oneself from the outside, and others from the inside’, and ‘thinking about feelings, and feeling about thinkings’.

Fonagy, Target, Gergely and their collaborators (Fonagy et al. 2002) see mentalising as a developmentally acquired skill, emerging in the first five years of life, gradually elaborated throughout the psychological life-cycle. They contrast mentalising with ‘pre-mentalising’ states of mind such as, in their terms, ‘pretend’ and ‘equivalence’ modes of thinking that developmentally precede it, and that may persist in psychopathology. In the former the individual withdraws from reality into a world of subjective desire and play; in the latter the thought–reality gap is obliterated, and the way the world is is assumed to be identical with, i.e. ‘equivalent’ to, the way one feels about it. Some may see in the contrast between mentalising and pre-mentalising modes of thought echoes of the Kleinian dichotomy of depressive and paranoid-schizoid positions. Whether the attachment perspective usefully adds to that dichotomy will be extensively discussed in Chapter 2.

The clinical impetus behind the elaboration of mentalising comes from trying to understand and help people suffering from borderline personality disorder (BPD), for whom ‘standard’ treatment approaches have had, at best, only modest success. There is now accumulating evidence for the effectiveness of mentalisation-based therapy (MBT) in improving the prognosis and life-course of BPD sufferers (Bateman and Fonagy 2008). Other specialised therapies such as transference-focused therapy and dialectical behavioural therapy have also shown good results.

An attachment-informed psychoanalytic credo

How do these attachment ideas link with the psychoanalytic viewpoint that is this book’s conjoined theme? A fundamental bridge between the two disciplines is modern evolutionary theory. Freud was a Darwinian (Sulloway 1980), seeing beneath the veneer of civilisation the mind’s earlier phylogenetic inheritance; emphasising adaptation as a mark of psychological health; and pointing to the necessary compromises that such contradictions entail.

Neo-Darwinism also underpins the science of ethology, one of attachment theory’s roots. Ethology shows that our near relatives such as baboons, living in close social groups, have a deep grasp of social relationships (Cheney and Seyfarth 2007; Suomi 2008). Non-human primates, if they are to flourish, must understand dominance hierarchies, social rank, sexual mores, security relationships, child-care arrangements and feeding precedence. Despite a limited and largely stereotyped expressive repertoire, non-human primates’ receptive ‘language of thought’ is manifest in subtle and varied behavioural ways – how they approach one another, whom they approach, how they react to threat, and in their feeding behaviours and mating preferences. Social relations, even though verbally inaccessible, are thus firmly represented in the primate mind. The psychoanalytic approach to infant observation (infans = without speech) similarly reconstructs a pre-verbal child’s ‘language of thought’ from observations of social context and behaviour, facial expression and affective communication. Psychoanalysis’ primary domain is this language of thought, and the capacity to give it voice.

Freud’s first great discovery, a theoretical one, was that in any intimate human relationship, two simultaneous ‘conversations’ are in play: conscious and unconscious, or verbal and non-verbal (Freud 1911). In ‘normal life’ the non-verbal, biologically salient, aspects of communication are concealed or repressed. Telephoning a friend, I assume that I am just telephoning a friend – not counting on her to protect or feed me, wondering whether we might go to bed together or form an alliance against a stronger competitor. This leads us to the fundamental paradox with which psychoanalysis is concerned. On one hand, to become conscious of the sexual, competitive, hierarchical, security-seeking aspects of interaction is inherently disturbing. On the other, not to be aware of this domain means running the risk of sleepwalking into and through relationships, driven by forces of which one is largely unaware.

In order to think about this dilemma – to be aware is to suffer, and yet not to be aware may lead to even greater suffering in the long run – security is essential. Anxiety is the enemy of mentalising. An attachment figure is required to whom we can turn, and the more secure that attachment, the more capable we will be of exploring our true nature.

For Bowlby, attachment and love were synonymous. The secure base is his ‘good object’. A secure base-provider is accessible when needed and is uniquely capable of understanding the care-seeker. To be a good object one has to be able to put oneself in another’s shoes and to comprehend the nature of their experience. A secure base is there to carry one over the cracks and fissures – ‘ruptures’ – in human relationships. The secure base/good object is able to withstand the protest that separation evokes, while continuing to hold the loved one in mind.

Freud’s second great invention, a practical one, was that of the consulting room and the couch. The analytic relationship is an in vitro experiment in intimacy. The consulting room is a place in which the language of thought begins to be articulated – fear formulated, desire described, sorrow given words. The analyst is an attachment figure who provides the security needed for insecurity to be explored. Insecurity is precisely that which the analyst’s presence evokes – desire, rivalry, fear of rejection, humiliation, neglect, exploitation, and so on. What begins as ‘transference’ – unarticulated nonverbal relational resonance – ends up as ‘insight’, the ability to read one’s own ‘language of thought’ and that of others. In phantasy the analyst is the ‘one supposed to know’ (Zizek 2006), the expert on the ‘unthought known’ (Bollas 1987). As therapy proceeds the analyst disavows this, and, like an allergist, gradually helps the patient to expose themselves to manageable bits of their unconscious shames and fears.

Theory and practice in psychoanalytic psychotherapy

I justify this book on the grounds that there is a theory–practice gap in psychoanalytic psychotherapy (cf. Canestri 2006). As Fonagy elegantly puts it (Fonagy 2006a, p. 76), ‘clinical technique is not logically entailed in psychoanalytic theory’. Psychoanalytic therapy cannot be assembled from its theory in the way that a furniture flatpack arises effortlessly out of its instruction diagram (usually in my case with one or two screws loose!).

What goes on in sessions – verbally, non-verbally, interactionally, physiologically, consciously and unconsciously – is at best only partially captured by avowed theoretical positions. There is a need for a developmental-based, empirically underpinned meta-theory with which to study the minutiae of therapist–patient interaction. The contention of this book is that attachment theory can contribute to such a heuristic, with its clear account of what is and is not helpful in therapeutic relationships.

O’Neill (2008) usefully takes up Donnet’s (2001) notion of the psychoanalytic ‘site’. A ‘site’ is a geographical metaphor referring to the constellation of procedures, together with their theoretical underpinning, which constitutes the essence, location or ‘place’ of a particular cultural phenomenon.

Within psychoanalysis there are fierce debates about what constitutes ‘proper’ analysis. Given the plurality of theories and practices, the search for a ‘common ground’ has also proved elusive, seen as essential to psychoanalysis’ survival by some (Wallerstein 1990), an elusive chimera by others (Green 2005). In Tuckett et al.’s (2008) European Psychoanalysis project, analysts from different cultural, linguistic and psychoanalytic backgrounds examine one another’s work. They show how challenging it is for psychoanalysts from divergent traditions and nationalities to respect as valid ‘psychoanalysis’ methods of working that differ from their own. Faced with uncertainty, analytic charisma and arbitrary authority – and sometimes subtle contempt and denigration – replace exploration and open debate.

Tuckett et al. (2008) develop a framework attempting to understand and theorise what psychoanalysts actually do – as opposed to what they say, or think, they do. They classify psychoanalytic interventions in five broad categories:

1. ‘housekeeping’ remarks aimed mainly at maintaining the basic setting (e.g. ‘reminding you that I shall be away next week’)
2. brief ‘unsaturated’/‘polysemic’ (i.e. ambiguous) comments that further the analytic process (e.g. ‘walls!’, ‘a mouth without teeth?’!)
3. questions and clarifications
4. various forms of interpretive comment either on the here-and-now relationship with the analyst or forging links between present and past
5. spontaneous ‘mistakes’ (possibly induced enactments) on the part of the analyst – e.g. inappropriately reassuring comments – whose later exploration may bear analytic fruit.

Using a related but simplified classification (Castonguay and Beutler 2006), in what follows I shall be guided by a tripartite division of psychoanalytic interactions. After an extended discussion of mentalising, these are expanded, expounded, and explained in the three chapters that follow (cf. Holmes 2008a).

1. A therapeutic relationship with the following properties: (a) intensity; (b) ‘contingency’ in that the analyst is primarily responsive to the client’s initiatives; (c) a ‘secure base’ in which the client sees the therapist as able to contain and assuage her anxieties, however overwhelming; (d) once assuaged, enlivenment and ‘companionable interaction’ follow; (e) one that is continuously self-monitoring and self-repairing.
2. A primary task of meaning-making in which analyst and client begin to make sense of problematic or symptomatic experiences and behaviours. The primary data for this sense-making process are: (a) free association in which the ‘material’ brought to the session by the client is analysed as much for its relationship to the client’s inner world as for its manifest content; (b) dreams; (c) language, in which words are seen as manifestations of chains of unconscious meanings; (d) the therapeutic relationship itself, i.e. transference feelings and enactments evoked by the therapeutic process; (e) patterns in the client’s developmental history, in which the long-term implications of infantile and childhood trauma are explored.
3. Therapeutic action or change, brought about by inducing tension or a ‘benign bind’ that: (a) helps promote the client’s capacity to think about his own feelings and actions and those of others; (b) helps the client to reintegrate repressed, disowned or projected affects or parts of the self with resulting greater sense of vitality, efficacy and ‘real-ness’; (c) enhances emotional articulacy, including mourning and processing past losses and traumata; (d) replaces rigidity and transference-driven repetitiousness with more creative, fluid, interpersonal and narrative capacities.

Darwin showed incontrovertibly (but not uncontroversially) that evolution by natural selection was the best possible explanation for the origin of species, but until the advent of genetics he was in the dark as to its underlying ‘mechanism of action’. Similarly, we know for sure that psychoanalytic psychotherapy ‘works’ (see Chapter 5), but we do not know how or what is it about it that produces change – therapeutic charisma, accurate interpretation, secure attachment, instillation of mentalising capacity, or some as yet unarticulated factor. The aim of this book is to explore how attachment theory can help towards a better understanding of this elusive DNA of our discipline.

Chapter 2

Mentalising

When I first encountered the term ‘mentalising’ I found it off-putting, with its abstract pseudo-technical ring, and wondered if this was not yet another example of Molière’s bourgeois gentleman discovering that he had been speaking prose all his life. I have come round to the view that mentalising captures a crucial aspect of psychological health, and psychotherapists’ efforts to promote it. The aim of this chapter is to take the reader on a similar intellectual journey.

As stated in the previous chapter, the term, and its related noun mentalisation, were introduced to the Anglo-Saxon world by Fonagy, Target, Gergely, Bateman (Bateman and Fonagy 2004, 2008; Fonagy et al. 2002) and Allen (2006, 2008) as part of a project aiming to improve the treatment of people suffering from borderline personality disorder. But mentalising can be seen as a much wider theme permeating psychotherapy generally. In what follows I shall track its definition, phenomenology, intellectual roots and clinical applications.

Bollas (2007) states that the greater the number of theoretical approaches available to the analyst, the better equipped she is to respond to the variety of experiences she meets in the consulting room. Bion (1962, p. 88), by contrast, states that ‘psycho-analytic virtue lies not in the number of theories the psychoanalyst can command but the minimum number with which he can meet any contingency’. In this chapter we shall look at whether mentalising passes this stringent Bionic parsimony test, offering a useful and genuinely new perspective on our work.

Definition

Neither mentalising nor mentalisation is to be found in the Shorter Oxford English Dictionary or Chambers Dictionary; nor do they appear in Rycroft’s (1995) or Laplanche and Pontalis’ (1973) psychoanalytic thesauruses. Bateman and Fonagy (2004, p. xxi) define mentalising as ‘the mental process by which an individual implicitly and explicitly interprets the actions of himself and others as meaningful on the basis of intentional mental states such as personal desires, needs, feelings, beliefs and reasons’ (emphasis added).

This definition suggests several interrelated aspects of the concept. Mentalising is ‘meta-cognitive’, in the sense that it refers to the capacity for interpretation of thoughts and actions – to think about thinking, to be ‘mind-minded’ (Meins 1999). Nevertheless, mentalising is not primarily an intellectual or rational phenomenon. Full-blown explicit mentalising is a three-stage process. Firstly, it is experiential in the sense that its starting point is an ‘automatic’ affective response – a ‘thought’ often accompanied by somatic sensations and/or images. This is followed, secondly, by awareness or ‘noticing’ what one is thinking and feeling. Thirdly, and only in explicit as opposed to implicit mentalising, there is thinking about what one has caught oneself thinking about.

In implicit mentalising these processes also occur, but below the surface of awareness. People manage to walk down the street mostly without bumping into one another. The mind ‘computes’ others’ trajectory and intentions and one’s own to guarantee safe passage. Only when this goes wrong does the process need to become explicit and conscious – when walker A goes right at exactly the moment walker B coming in the opposite direction thinks she is going left, and they all but bump into one another, often with an moment of acknowledgment and mutual amusement.

Next, mentalising is concerned with the meanings that we attribute to our own and others’ actions – that is, to the implicit or explicit hypotheses we use to understand why we, or another, might have thought or done such and such a thing. This links with a third aspect, which picks up on mentalising as a key attribute of persons, as opposed to the inanimate world. Implicit in mentalising is Dennett’s (1987) intentional stance – the capacity to have projects, desires and wishes. Mentalising is related to empathy in that it implies the ability to put oneself in another’s shoes – to see the other as a sentient person, as opposed to a ‘thing’. Finally, mentalising is not a fixed property of mind, but a process, or skill, that may be present or absent to greater or lesser degrees.

The Fonagy–Target model of mentalisation arises out of research using the Adult Attachment Interview (AAI) (Fonagy et al. 1997). The ‘reflective function’ subscale provides an operationalised quantitative measure of the capacity for mentalising. Transcripts of AAI are rated using a number of criteria listed below (Bateman and Fonagy 2...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Preface
• Acknowledgements
• Part I
• Part II
• References