Attachments: Psychiatry, Psychotherapy, Psychoanalysis

The selected works of Jeremy Holmes

Jeremy Holmes

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317647119
• Edition: 1
• Topic: Medicina
• Subtopic: Psiquiatría y salud mental

For three decades Jeremy Holmes has been a leading figure in psychodynamic psychiatry in the UK and across the world. He has played a central role in promoting the ideas of John Bowlby and in developing the clinical applications – psychiatric and psychotherapeutic – of Attachment Theory in working with adults. Drawing on both psychoanalytic and attachment ideas, Holmes has been able to encompass a truly biopsychosocial perspective. As a psychotherapist Holmes brings together psychodynamic, systemic and cognitive models, alert to vital differences, but also keenly sensitive to overlaps and parallels.

This volume of selected papers brings together the astonishing range of Holmes' interests and contributions. The various sections in the book cover:

An extended interview – covering Holmes' career and philosophy as a psychodynamic psychiatrist

'Juvenilia' – sibling relationships, the psychology of nuclear weapons, and the psychodynamics of surgical intervention.

Psychodynamic psychiatry: Integrative and Attachment-Informed

A psychotherapy section in which he develops his model of psychotherapeutic change

'Heroes' – biographical pieces about the major influences including, John Bowlby, Michael Balint, David

Malan, Jonathan Pedder and Charles Rycroft.

'Ephemera' – brief pieces covering such topics as frequency of psychodynamic sessions and fees.

Attachments: Psychiatry, Psychotherapy, Psychoanalysis - The Selected Works of Jeremy Holmes will be essential and illuminating reading for practitioners and students of psychiatry and psychotherapy in all its guises.

PART I

AUTOBIOGRAPHICAL

Dianna Kenny and I have never met, yet, in the spirit of the age, we have had several in-depth transcontinental conversations via the internet. Professor Kenny and her publishers have kindly allowed me to include an extract from her book From id to intersubjectivity: Talking about the talking cure with master clinicians (London: Karnac Books, 2013), which enables me to set the scene for the rest of this volume and gives the reader some idea of my background, education, and development as a psychiatrist, attachment enthusiast and psychotherapist. ‘Ten books’ is a regular series in the British Journal of Psychiatry in which psychotherapists of differing persuasions are invited to reflect, Desert Island Disc-style, on the reading that has shaped their thinking.

CHAPTER 1

INTERVIEW WITH DIANNA KENNY

DK:	Let’s start by your telling me about the personal and/or professional experiences that directed you into the profession of psychoanalysis and, in particular, attachment-informed psychoanalysis?
JH:	I am the oldest of three, with two younger sisters. I sometimes describe myself as culturally Christian, intellectually atheist, ethically Buddhist, and ethnically Jewish – our mother was a secular Jew and Freud’s Introductory lectures was sitting on our parents’ bookshelf. Our father was an actor, newsreader and poet; we had a liberal upper-middle-class London upbringing with rural overtones – my father had grown up on a farm. There were no scientists in the family, although there was a great-aunt who was a doctor – quite something for a girl in the 1920s. The family culture was in humanities and arts, but I was fascinated with physics, cosmology and biology, and my career ambition was to become a research scientist. Once I got to Cambridge I realised that I would never make a real scientist and, more to the point, that I needed to earn my living. This, together with vague adolescent aspirations to alleviate Third World suffering, and thinking that another three years as student would not come amiss, I decided to train as a doctor.
	This was the heyday of R. D. Laing. His associate David Cooper came to Cambridge and gave a lecture; we all crammed in to hear him. I can’t remember a word he said. Until that moment, as an ‘infantile leftist’, I wanted to change the world. Cooper’s message was: you can’t change the world; you can only change yourself. That was the moment I decided to do medicine and then psychiatry. My clinical years were at University College London. We had some wonderful lecturers – Michael Balint and Heinz Wolf, who were very charismatic, especially for medical students. I learned from them that psychiatry can be humane and psychodynamic. For a while, however, I was diverted out of psychiatry and became a physician, with a particular interest in psychosomatics. After that I started psychiatry training and gravitated naturally to the psychodynamic end of psychiatry (the science/arts divide is ubiquitous, like left and right in politics). I also then went into analysis myself. I needed help. Charles Rycroft was my analyst. Despite retrospective reservations about Charles clinically (he was far too ‘supportive’ and didn’t seem to understand transference), I see myself as within his tradition. I am highly sceptical of psychoanalytic fundamentalists. But John Bowlby was my intellectual father; I revere Bowlby – he is a giant. He brought a humane yet scientific approach to the mind, as opposed to dogma and doctrine. In terms of my own development, I suppose I identify to some extent with Bowlby, although he came from a much ‘posher’ background than I did – we both had war-torn childhoods. Bowlby was a bit avoidant, as was I. Both our fathers were absent during crucial years. Charles Rycroft’s father died when Rycroft was 11 – so there’s some sort of ‘paternal deprivation’ story there. Attachment theory felt like a natural home to me – it’s a marriage of psychoanalysis and evolutionary biology and ethology. Jung said that psychological theories are a disguised form of autobiography. Unconscious forces influence our conscious thoughts – we need to understand imaginative leaps in great scientists in the light of their developmental history, as Bowlby did in his last great work, the Darwin biography.
DK:	How do you identify yourself?
JH:	As a medical doctor, a psychiatrist and a psychoanalytic psychotherapist. I am not a member of the International Psychoanalytic Association (IPA) because I have not trained as a psychoanalyst. I side-stepped this form of control and this hierarchy – but of course also missed out on the cross-fertilisation and camaraderie and evaded the necessary submission to the yoke of authority. I was, naturally, influenced by Rycroft, who eventually left the IPA, and Bowlby, who remained a member of the IPA but was persona non grata for many years within the British society. I am also a maverick. Maverick was a cattle rancher. Cattle ranchers branded their cattle to prove ownership, but Maverick refused to brand his – a humane move, but it meant they got muddled up with everyone else’s! I am a natural integrative psychotherapist. I have been influenced by a range of therapies, including CBT, psychodrama and family therapy; I am totally anti-branding.
DK:	Could you say something more about how you define psychoanalysis and the nature of the relationship between analyst and patient?
JH:	My basic model of the analytic relationship is the parent–child relationship – securely attached children have a different developmental history compared with insecurely attached children. Maternal sensitivity correlates with security. But there is a ‘transmission gap’ – the term ‘sensitivity’ is vague: what is it that makes mothers sensitive? There is a similar issue with defining the therapist–patient relationship. We know that therapy ‘works’ but not what it is that produces change – is it therapist sensitivity? If so, what are its components? This is still an empirical question.
	Beebe (Beebe et al., 2012) is very interested in facial gestures between mothers and infants. One of her studies looked also at vocal communication. She got mums to sing along with their babies and recorded the melodic relationship between mothers’ and infants’ vocalisations. When the children reached one year of age, she classified their attachment using the Strange Situation. Mothers fell into three categories: one group was tone deaf; the second group sang in unison with their infants; and the third group sang in a more harmonic and jazzy way. The infants of these mothers were more likely to be secure than the infants of either of the other two groups of mothers. This was a lovely empirical demonstration of what I call partially contingent mirroring. ‘Photographic mirroring’ is not sufficient; partially contingent mirroring seems to be one of the things that therapists do with their patients. They mirror, and then take them a step further.
DK:	Is there a meaningful distinction between psychoanalysis and psychodynamic psychotherapy?
JH:	There is no absolute distinction between these terms; they are terms of convenience, of politics. Timing/frequency has little to do with the definition of how ‘analytic’ a therapy is. The discrepancy between what people say they do and what they actually do is one of my hobby-horses. Nothing extraordinary will happen just because someone is having a therapy five days a week. All frequencies of therapy will involve transference and counter-transference and defences if the therapist is working from a psychoanalytic perspective.
	The main power of therapy can’t be fully defined in terms of specific elements. Change comes as much from the ‘non-specific’ aspects, especially from the therapeutic relationship. There is an established relationship between good outcomes and length of treatment, but the theoretical position is not so important. The skill of the therapist is a better contributor to outcome than the type of therapy practised. We also know that, the longer a therapy goes on, the less theoretically driven it becomes. The quality and character of that relationship is a feature of those two individuals, so each long-term psychoanalytic dyad has its own character. As a therapy goes on, so the ‘third’ takes over and is a manifestation of the joint projects and personalities of analyst and patient.
DK:	What aspects of classical Freudian analysis remain in attachment-informed psychotherapy?
JH:	In the classical paradigm, defences are forms of affect regulation. In the attachment paradigm, the purpose of defences is also affective regulation, but, in addition, they are ways of maintaining contact with an object in suboptimal environments. It is the type and quality of interpersonal contact that creates the defence. In the classical psychoanalytic model, defence mechanisms are located within the individual. In the attachment relational model, they are essentially interpersonal. I am interested in the way in which the care-giver helps the infant cope with his overwhelming affect of fear or hunger or feeling of abandonment – and, indeed, excitement – and how this interpersonal field is translated into the consulting room, where there is a reworking of the handling of affect. That can be done ‘defensively’, where affect is suppressed, as in the deactivating strategy. In a secure-making relationship, the affect can be dealt with in manageable small amounts through the presence of a sensitive care-giver. I think there is a radical difference there. The role of the analyst isn’t just to interpret the defence mechanisms; it is to rework the defence mechanisms while at the same time commenting on them. That, I think, is the essence and the skill and the difficulty and the excitement and the frustration of psychoanalytic work. One is simultaneously engaging with the patient and helping the patient to find a vantage point from which they can observe this relationship.
	My latest idea is that there is this five-stage model that I think applies to all intimate relationships.
	Stage one is what I call the primary attachment relationship. A lot of the attachment literature focuses on the care-seeker, on the child and the infant, and how stress and threat and illness activate the attachment dynamic and then a secure base is sought. But there is a parallel process in the care-giver. When we are presented with distress, we are biologically programmed to respond to that distress, whether it be a small animal, a stranger who is injured, or one of our loved ones – children, spouses, partners, pets, or even our plants – that needs attention. I live in a rural area; there are sheep and lambs there. When the ewes see me coming, they immediately call their infants, their baby lambs, to come them because they see a potential threat. There is this reciprocal biological relationship. In Stage one, we as therapists respond to distress; and what do you do when you respond to distress? You set your own preoccupations to one side. You immerse yourself in the vulnerability of the care-seeker. From an attachment perspective, Bowlby saw this in terms of what he calls the environment of evolutionary adaptation. Infants are not going to survive in the primitive savannah unless adults are highly protective of them. This primary attachment relationship is a little bit like Winnicott’s notion of primary maternal preoccupation, which is unconscious, not in the classical psychoanalytic sense, but in the sense that it is biologically programmed.
	Stage two is what I call reverie. Now you allow yourself to enter empathically into the inner world of the patient, so you can, to use Thomas Ogden’s phrase, dream your patient. You experience your patient inside yourself. We are beginning to understand the neurobiological aspect, including mirror neurons. Something is triggered off in us by our patient’s distress which enables us imaginatively to put ourselves in the patient’s shoes.
	Stage three I call logos, and this is related to interpretation. The empathic resonance of stages one and two is only part of the story because it has to be turned into a shared meaning between patient and therapist, which they can then use. You are giving this logos, this interpretation, this comment, to the patient, but you must be in empathic resonance with her also in order to help with that patient’s affect regulation. The great thing about the consulting room is it doesn’t matter what you say because it’s a hypothetical situation; you can do things there that you wouldn’t perhaps be able to do in real life.
	Stage 4 is what I call action or decision or consequence. This flows from the therapeutic relationship in terms of change in the person’s life but also from the arrangements of therapy, how long to go on, when to terminate, etc.
	Finally, Stage 5 is reflection. You loop back and look at the whole process, finding a vantage point from which to view what happened, what went right, what didn’t, and so on.
DK:	Let’s go back to the interpersonal, attachment models of defences.
JH:	They are certainly interpersonal at the start. Let’s say you are a six- or nine-month-old child and you have a stressed mother. She may be stressed socio-economically, she may be wondering where she is going to get her next meal from or how she can pay the mortgage, she may be having marital conflict, she may not have a partner. But you are an infant and you need your mother’s protection because, as Winnicott says, there is no such thing as a baby. An infant without her parent or protector will die. You become distressed; if you express too much affect, your mother, rather than being able to help you with that and soothe you, may push you away. It may be too much for her. So you learn a defence mechanism – let’s say deactivation. You close down your feelings. That way your mother will protect you but you pay a price: you are not so much in touch with your feelings; your affective universe is diminished, your pleasure in life may be diminished; your flexibility is compromised. There are trade-offs in all aspects of psychological life. Here the trade-off is that security takes precedence over affective expression. That’s looking at a defence mechanism from an interpersonal perspective. There are continuities between defensive and interpersonal patterns in early childhood and adult life, which is quite remarkable and just what Freud predicted. The child I have just described may grow into an adult who is ‘dismissive’, as measured in the adult attachment literature – someone who needs relationship but, when in a relationship, is unable to express themselves fully; they are unable to respond to their partner’s emotional needs or they expect their partner to be responsive to their emotional needs. They will be relationally compromised, handicapped even. If that person then comes into therapy, that relationship will be reproduced in the therapy situation. The patient will present a rather affectless account of their life. If therapy is successful, therapy provides a setting in which it gradually becomes more and more safe to express the affect which they suppress, and that enables a reworking of the defensive structures and perhaps possibly a move to more mature defensiveness. They may be able to make a joke about their feelings, which is better than not expressing feelings at all. That would be a move from repression to suppression to using a mature defence such as humour. That is an attachment perspective on the psychotherapeutic task.
	One of the crucial growth points currently in this way of looking at things is the concept of disorganised attachment and the relationship between disorganised attachment and psychopathology. Disorganised attachment is relatively uncommon in non-clinical populations but very common in psychopathology. Where you have highly stressed care-givers, where children present to clinics, where there is a history of physical or sexual abuse in the family, then disorganised attachment is very prevalent. Splitting, dissociation and role reversal are the common defences, whereby you project your own vulnerability onto another person and look after it ‘over there’ rather than in yourself. Those are typical patterns you see in disorganised attachment, and they are highly relevant to one of the big issues for psychoanalytical psychotherapy, Borderline Personality Disorder, and the kinds of therapeutic strategies that are going to be helpful with such people.
DK:	Can you say something about ‘mentalising’, a term that is much used in the attachment-informed therapeutic literature these days.
JH:	The word ‘mentalising’ comes from the francophone literature and was introduced into English by Peter Fonagy in the late 1980s. That flowed directly from Mary Main’s notion of ‘meta-cognitive monitoring’. What goes on in the consulting room is a way of fostering the client’s capacity to mentalise. I mentioned the metaphor of a vantage point. Therapy, the consulting room, provides a vantage point from which a person can begin to look at themselves, especially themselves in relationship. Therapy is a relationship that can also look at itself. Therapist and patient together look at themselves in action, and this process fosters the capacity for mentalising. Borderline Personality Disorder is a disorder of affect regulation in the sense that the borderline person very quickly becomes affectively aroused – ‘I have had enough of this, I’m off’ – and they storm out of the session. I heard a lovely example in a supervision session recently where the patient looked at the therapist’s bookshelf and said, ‘I am going to pick all those books up and throw them across the room’, and the therapist, who in a previous life had been a school-teacher, said, in a very ‘school-marmy’ voice, ‘You most certainly will not.’
	Now, that would actually be a very good exampl...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Acknowledgements
• PART I Autobiographical
• PART II Juvenilia
• PART III Psychodynamic psychiatry
• PART IV Psychotherapy: integrative and attachment-informed
• PART V Heroes
• PART VI Ephemera
• Sources
• References
• Index