No More Learning

Second, it starts from the observation of normal development, which can then be used as a yardstick against which to understand psychopathology, rather than building a theory of normal development from inferences made in the consulting room. It is perhaps no accident that the psychoanalyst with whom Bowlby has most in common, Winnicott, was also keenly aware of normal developmental processes through his earlier work as a pediatrician. Winnicott and Bowlby both believed that their observations of normal development were relevant to psychotherapy, for by getting a picture of what makes a good parent, we are likely to be in a better position to know what makes a good psychotherapist.
MARY AINSWORTH AND THE STRANGE SITUATION
There is an intimate relationship between technology and scientific advance. Galileo's observations depended on the expertise of the sixteenth-century Italian lens grinders; Darwin's discoveries sprang from the navigational and cartographic skills of Victorian maritime imperialism. Ainsworth's 'Strange Situation', 'a miniature drama in eight parts' (Bretherton 1991a) for mother, one-year-old infant and experimenter, has established itself as an indispensable tool in developmental psychology.
Ainsworth devised the Strange Situation in the late 1960s as part of her studies of mother-child interaction in the first year of life. She had worked with Bowlby in the 1950s, then moved to Uganda where she had made naturalistic studies of mothers with their babies, and finally settled in Baltimore, Maryland. Influenced by Attachment Theory, although at first wary of its ethological bias, she was interested in the relationship between attachment and exploratory behaviour in infants, and wanted to devise a standardised assessment procedure for human mothers and their children which would be both naturalistic and could be reliably rated, comparable to the methods used by animal experimenters like Harlow (1958) and Hinde (1982b).
The Strange Situation (Ainsworth et al. 1978) consists of a twenty-minute session in which mother and one-year-old child are first introduced into a playroom with an experimenter. The mother is then asked to leave the room for three minutes and to return, leaving the child with the experimenter. After her return
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and the re-union with the child, both mother and experimenter go out of the room for three minutes, leaving the child on its own. Mother and child are then once more re-united. The whole procedure is videotaped and rated, focusing particularly on the response of the child to separation and re-union. The aim is to elicit individual differences in coping with the stress of separation. Initially three, and later four, major patterns of response have been identified:
1. Secure attachment ('B') These infants are usually (but not invariably) distressed by the separation. On re-union they greet their parent, receive comfort if required, and then re- turn to excited or contented play.
2. Insecure-avoidant ('A') These children show few overt signs of distress on separation, and ignore their mother on re-union, especially on the second occasion when presumably the stress is greater. They remain watchful of her and inhibited in their play.
3. Insecure-ambivalent (insecure-resistant) ('C') They are highly distressed by separation and cannot easily be pacified on re- union. They seek contact, but then resist by kicking, turning away, squirming or batting away offered toys. They continue to alternate between anger and clinging to the mother, and their exploratory play is inhibited.
4. Insecure-disorganised ('D') This small group has recently been demarcated. They show a diverse range of confused behaviours including 'freezing', or stereotyped movements, when re-united with their parent.
In Ainsworth's original middle-class Baltimore sample the proportions were 'B' (secure) 66 per cent, 'A' (avoidant) 20 per cent, and 'C' (ambivalent) 12 per cent. 'D' had not been identified at that stage. Since her original publication, the Strange Situation has been used in well over thirty different studies (Ijzendoorn and Kroonenberg 1988), and is generally accepted as a reliable and valid instrument - comparable perhaps to the widespread use of the Expressed Emotion scales in psychiatry (Left and Vaughn 1983; see Chapter 9). There are significant cross-cultural variations, so that 'A' (avoidant) classifications tend to be commoner in Western Europe and the United States, while 'C' (ambivalent) is commoner in Israel and Japan. Intra-cultural
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variation between different socio-economic groups and between disturbed and non-disturbed families is greater than inter-cultural variance.
A whole set of research and theoretical questions follows from the establishment of this robust research tool. What is the meaning of the different patterns of response? Are they stable over time, and if so for how long? Do they predict disturbed behaviour later in childhood? Do they, as psychoanalytic theory might assume, persist into adult life? Can they be related to patterns of maternal- infant interaction in the early months of life? If maternal handling is relevant to classification pattern, what is the relationship between this and the mother's own experience of being mothered? If so, what are the psychological mechanisms by which attachment patterns are carried over from one generation to the next? Can patterns be altered by therapeutic intervention? The remainder of this chapter will be devoted to a discussion of these and related questions.
THE ROOTS OF SECURE AND INSECURE ATTACHMENT
Bowlby saw personality development primarily in terms of environmental influence: relationships rather than instinct or genetic endowment are primary. Differing patterns of attachment result from differing patterns of interaction, rather than being a reflection of infant temperament, or instinct. Sroufe (1979) makes an important distinction between 'emergent patterns of personality organisation' as revealed in the Strange Situation, and temperament, the latter representing quasi-physiological styles of behaviour, while the former reflect much more complex habitual relationship patterns. Thus babies may be sluggish, or active, 'cuddly' or non-cuddly, slow or fast, but still be classified as secure. Even more telling is the finding that children have different, but characteristic, attachment patterns with their two parents, and may be classified as secure with one and insecure with the other. This argues strongly that attachment patterns are a feature of the parent-child relationship, as yet not 'internalised' at one year, although by 18 months patterns have become more stable, with maternal patterns tending to dominate over paternal.
The Strange Situation research was part of a much larger study in which Ainsworth and her colleagues visited mothers and their
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infants regularly for periods of observation and rating during the whole of the first year of life. She found that attachment status at one year correlated strongly with the maternal relationship in the preceding twelve months, and this finding has been replicated in several other centres (Main and Weston 1982; Grossman et al. 1986; Sroufe 1979). In summary, prospective studies show that mothers of secure one-year-olds are responsive to their babies, mothers of insecure-avoidants are unresponsive, and mothers of insecure-ambivalents are inconsistently responsive.
The key to secure attachment is active, reciprocal interaction (Rutter 1981), and it seems that it is quality of interaction more than quantity that matters - a finding that contradicts Bowlby's earlier view on the causes of maternal deprivation. Passive contact alone does not necessarily promote attachment. Many babies are strongly attached to their fathers even though they spend relatively little time with them, and kibbutzim-reared children are more strongly attached to their mothers than to the nurses who feed them and look after them during the day, but often without much active interaction. In the first three months, mothers of secure infants respond more promptly when they cry; look, smile at and talk to their babies more; and offer them more affectionate and joyful holding. Mothers of avoidant children tend to interact less, and in a more functional way in the first three months, while mothers of ambivalents tend to ignore their babies' signals for attention and generally to be unpredictable in their responsiveness. By the second half of the first year, clear differences can be detected in the babies, and those who will be classified as secure at one year cry less than the insecure group, enjoy body contact more, and appear to demand it less (Bretherton 1991b).
The factor which mothers of insecurely attached children have in common can be understood in terms of Stern's (1985) concept of maternal attunement. He shows how sensitive mothers interacting with their children modulate their infant's rhythms so that when activity levels fall and the infant appears bored the mother will stimulate them, and when the child becomes overstimulated the mother will hold back a little so as to restore equilibrium. In cross-modal attunement the mother follows the baby's babbling, kicking, bouncing and so on with sounds or movements of her own that match and harmonise with those of the baby, although they may be in a different sensory mode. As he bounces up and down she may go 'Oooooh . . . Aaaaah . . . ',
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matching the tempo and amplitude of her responses to the baby's movements. This helps, as Stern sees it, in the development of the infant's sense of integrated selfhood. These processes of attunement are impaired in mothers of insecurely attached infants, leading to 'derailment' or mismatching in maternal response (Beebe and Lachmann 1988): thus mothers of ambivalently attached children can be observed to force themselves on their children when they are playing happily, and ignore them when they are in distress.
Brazelton and Cramer (1991) propose a similar model in which they break down the components of secure mother-child interactive patterns into four main features: synchrony (temporal attunement), symmetry (matching of actions), contingency (mutual cueing), and 'entrainment' (the capturing of each other's responses into a sequence of mutual activity). On the basis of this, play, and later infant autonomy, begins to emerge. Insecure attachments result from intrusiveness or under-responsiveness. They have developed an experimental model of the latter in their 'still face' experiments in which the infant is momentarily presented with an unmoving image of the mother, who is prohibited from picking up the baby or responding to it. The baby shows disappointment, gaze aversion and self-soothing strategies, which match those seen in the children of clinically depressed mothers.
As we have seen in the previous chapter, aggression is a major component of the initial response to threatened separation. Both patterns of insecure attachment can perhaps be understood in terms of the interplay between the need for attachment and the aggressive response to the threat of separation. The ambivalently attached child shows overt aggression towards the inconsistent mother who, in the Strange Situation, has just 'abandoned' him for two successive periods (albeit only for 3 minutes - but how was the one-year-old to know that? ). It is as if he is saying, 'Don't you dare do that again! ', but clinging on at the same time since he knows from experience that she will. The avoidant child shows little overt aggression in the Strange Situation, although these children do show outbursts of unprovoked aggression at home. It may be that the avoidant response is a way of dampening aggression and so appeasing the mother to whom the child needs desperately to feel close, but whom he fears will rebuff him if he reveals his needs too openly, or shows her how angry he feels about being abandoned (Main and Weston 1982).
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The clock-watcher
A clinical example of avoidant attachment in adulthood is provided by a patient who, although faithfully reliable in her attendance at therapy, found it difficult to enter affectively into sessions which consisted mostly of a catalogue of the preceding week's events. She was meticulous about timekeeping, kept a close eye on her watch throughout the sessions, because, she said, she was terrified to overrun by a single second. As a solicitor she knew how annoying it was when clients outstayed their allotted time. The effect of this clock-watching was quite irritating to her therapist, who commented that timekeeping was his responsibility and tried to persuade her to remove her watch for sessions. It then emerged that her phantasy was that without her watch she would get 'lost' in the session, lose control of her feelings and at just that moment the therapist would announce that it was time to stop; she would then get so angry she would 'disgrace' herself, the therapist would not tolerate this and would break off the treatment. She had been a rather 'good' if distant child who had spent a lot of time on her own, while her older sister had been renowned for her tantrums and angry outbursts. By keeping her distance in a typically avoidantly-anxious pattern, she had maintained some sort of contact with her therapist (and presumably as a child, her parents), while avoiding the danger of threatening her tenuous attachments with her rage. She also kept some sort of coherence in the face of fear of disintegration. The price she paid for this adaptation was affective distancing, low self-esteem ('He would not tolerate me if he knew what I was really like') and the lack of a sense of movement and growth in her life.
THE STRANGE SITUATION AS A PREDICTOR OF SOCIAL ADJUSTMENT
The idea that anxious attachment patterns represent an adaptation or compromise to a sub-optimal environment is borne out by follow-up studies of children classified at one, and tested at pre- school, on school entry and again at ten (Bretherton 1985). At two years, securely attached children have a longer attention span, show more positive affect in free play, show more confidence in using tools, and are more likely to elicit their mother's help in
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difficult tasks compared with anxiously attached children. Their nursery teachers (blind to attachment status) rate them as more empathic and compliant and higher on positive affect. In peer interaction avoidants are hostile or distant, while ambivalents tend to be 'inept' and to show chronic low-level dependency on the teacher, and to be less able to engage in free play by themselves or with peers.
Evidence that the patterns of behaviour defined by the Strange Situation behaviour carry forward into subsequent development comes from the Grossmans (1991), who have shown that patterns of behaviour on re-union were 87 per cent predictable between one year and six years. They also showed that six-year-olds classified at one year as secure played concentratedly and for longer, were more socially skillful in handling conflict with their peers, and had more positive social perceptions, compared with children who had been rated as insecure as infants. Sroufe (1979) sees secure-rated children as having greater ego control and ego resiliency than those who were insecure. Secure children were rated by their teachers as neither overcontrolled nor undercontrolled, while avoidants were overcontrolled, ambivalents undercontrolled. Resiliency was inferred from such statements as 'curious and exploring', 'self-reliant, confident'. Stroufe concludes: 'What began as a competent caregiver-infant pair led to a flexible resourceful child. . . . Such predictability is not due to the inherently higher IQ of the securely attached infant, or, apparently, to inborn differences in temperament. '
LANGUAGE, NARRATIVE, COHERENCE
So far we have confined our account to attachment behaviour. As we look now at older children and their mothers, we turn to the trickier but psychotherapeutically more salient topics of the nature of attachment experience, its internal representation and how it manifests itself in language.
Main et al. (1985), Bretherton (1991b) and Cassidy (1988) have tried to tap into the child's experience of attachment by the use of play techniques such as a picture completion task, story completion, and puppet interview and story all depicting in different ways episodes of separation and re-union. Children tend to reveal their attachment histories through their play and imaginative activity. Avoidant children at six tend to draw figures
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with blank faces and no hands, suggesting a lack of responsiveness and holding in their lives. Secure children in response to a picture- story task give coherent, elaborated responses, including references to their own separation experiences, and are able to suggest positive ways in which separated figures could resolve their difficulties. Avoidant children, by contrast, describe separated children as sad, but cannot think of ways to help them. Secure children at six were more able to give a balanced view of themselves as good, but not perfect, while insecure children saw themselves as either faultless or bad. It should be noted that these results were much more consistent for the avoidant than the ambivalent group who gave very varied responses to the play tasks, without a clear pattern emerging. The disorganised group ('D') emerged more clearly in these as opposed to previous studies, showing bizarre or disorganized responses to picture- and story- completion tasks.
Main (1991) presents some remarkable preliminary findings of a follow-up study in which ten- and eleven-year-olds, who had been classified in the Strange Situation at one year, were asked for a spoken autobiography. There was a 75 per cent correspondence between classification at one and at ten. Compared with the insecurely attached, the secure children's stories were consistently more coherent, had greater access to memories, especially of their pre-school years, and showed more self-awareness and ability to focus in on their own thought processes, a phenomenon Main calls 'megacognitive monitoring' - the ability to think about thinking.
The findings so far, which represent more than a decade of 'post-Bowlbian' research into Attachment Theory, can be summarised as follows. Relationship patterns established in the first year of life continue to have a powerful influence on children's subsequent behaviour, social adjustment, self-concept and autobiographical capacity. These effects last for at least ten years. Mother-infant relationships characterised by secure holding (both physically and emotionally), responsiveness and attunement are associated with children who are themselves secure, can tolerate and overcome the pain of separation, and have the capacity for self-reflection.
These results undoubtedly support the view that the early years of life play a crucial part in character formation, and show in a fascinating way the continuity between the pre-verbal infant self
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and the social self as we commonly conceive it. But two important qualifications need to be noted. First, since the parent-child relationship operates continuously as development proceeds, what we are seeing is not so much the result of some irreversible early events as an ongoing relationship with its own 'epigenetic' stability. There is evidence that if a mother's circumstances change - for example, a single parent entering into a stable relationship with a partner - then attachment status for her child may change, in this case from insecure to secure. Similar changes can occur, as we shall see later in the chapter, when mother and infant are both treated with psychotherapy (Murray and Cooper 1992). Second, in presenting these findings the emphasis has been on the contribution of the parent, especially the mother, with the infant's role being relatively passive. Clearly this is a gross oversimplification, and temperamental, or even neurological, factors in the child will play their part in the relationship with the parent, and subsequent social adjustment. Attachment status is quite a crude classification and clearly there will be a spectrum of subtle characterological features within it. Nevertheless, the evidence seems to be that the parent is the determining factor and that a 'good' mother even with a 'difficult' baby will, by one year, be likely to have a securely rather than insecurely attached child. For example, the amount a child cries at one year seems to depend more on the mother than the child: there is a strong correlation between prompt and sensitive maternal responsiveness to infant crying in the first three months of life and reduced (as compared with children of less responsive mothers) crying at one year, whereas there is no correlation between the extent of infant crying itself in the first three months and the amount of crying at one year.
This leads us directly to the issue of the inter-generational transmission of attachment. If relationships are in some way internalised by the growing child as 'character', what happens when that child grows up and becomes a parent? We know from Harlow's (1958) experiments that infant monkeys separated from their mothers show, when they become sexually mature, gross abnormalities in mating and parenting behaviour. Can we trace in the infinitely more complex language- and experience-based world of the human primate, connections between a mother's capacity to provide secure attachment for her child, and her experiences with her own mother when she was a child?
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THE ADULT ATTACHMENT INTERVIEW
The Adult Attachment Interview (AAI) was devised by Main and her co-workers (1985) as a tool for assessing the working models or inner world of the parent with respect to attachment. It is a semi-structured interview conducted along the lines of a psychotherapy assessment aiming to 'surprise the unconscious' into self-revelation (Main 1991). The subject is asked to choose five adjectives which best describe the relationship with each parent during childhood, and to illustrate these with specific memories; to describe what she did when she was upset in childhood; to which parent she felt closer and why; whether she ever felt rejected or threatened by her parents; why she thinks her parents behaved as they did; how her relationship with her parents has changed over time; and how her early experiences may have affected her present functioning.
The interviews are audiotaped and then rated along eight scales: loving relationship with mother; loving relationship with father; role reversal with parents; quality of recall; anger with parents; idealisation of relationships; derogation of relationships; and coherence of narrative. The 'state of mind with respect to attachment' of the interviewees can then reliably be assigned to one of four categories: Autonomous-secure, Dismissing-detached, Preoccupied-entangled and Unresolved-disorganised.
The Autonomous-secure parents give accounts of secure childhoods, described in an open, coherent and internally consistent way. Attachments are valued, and even if their experiences have been negative there is a sense of pain felt and overcome. The Dismissing-detached group give brief, incomplete accounts, professing to having few childhood memories and tending to idealise the past with such remarks as 'I had a perfect childhood'. Preoccupied-entangled parents give inconsistent, rambling accounts in which they appear to be overinvolved with past conflicts and difficulties with which they are still struggling. The Unresolved-disorganised category is rated separately and refers specifically to traumatic events such as child abuse which have not been resolved emotionally.
Several independent studies have shown remarkably consistent correlations between the attachment status of infants in the Strange Situation, and that of their mothers in the AAI. A number of retrospective studies have shown a 70-80 per cent correspondence
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between infant security and parental attachment status on the AAI. Thus Main and Goldwyn (1984) found that 75 per cent of secure infants had mothers who were rated Secure-autonomous, while mothers of avoidant infants tended to be Dismissing- detached, and ambivalent infants had Preoccupied-entangled parents. The Grossmans found 77 per cent correspondence, and Ainsworth 80 per cent. Even more striking are the findings of Fonagy and his co-workers (Fonagy et al. 1991), who administered the AAI to prospective parents during pregnancy and found that the results predicted infant attachment status in the Strange Situation at one year with 70 per cent accuracy. Of insecure infants 73 per cent had insecure mothers, and only 20 per cent of secure infants had insecure mothers, while 80 per cent of secure mothers had secure infants. The influence of fathers appeared to be less: 82 per cent of secure fathers had secure infants, but 50 per cent of insecure fathers still had secure infants. This supports the view that attachment status is a function of the infant-parent relationship, rather than of temperament, and also suggests that maternal, rather than paternal, insecurity is the more potent transmitter of insecure attachment across the generations.
Prospective findings were less clear-cut for the preoccupied parent-ambivalent infant correlation. Many ambivalent children had mothers who were apparently secure when given the AAI in pregnancy. However, Fonagy et al. (1992), on reviewing these interviews, found evidence of a certain 'fragility' in the replies of these mothers, suggesting a tendency to idealisation which could easily be mistaken for security. There is some evidence that ambivalent children may have shown physiological immaturity at birth, or are the products of difficult labours, and it is possible that immaturity in the infant may have exposed the mother's 'fragility' in such a way as to produce an ambivalent attachment status at one year.
THEORETICAL INTERLUDE
The findings of this new generation of post-Bowlbian researchers are summarised in Table 6. 1 and produce a coherent picture of benign and vicious cycles of security and insecurity. Secure mothers are responsive and attuned to their babies and provide them with a secure base for exploration. They are able to hold them, delight in them, and cope with their discontent and aggression in a
Table 6. 1 The continuity of secure and insecure attachment
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satisfactory way. These mothers have a balanced view of their own childhoods which, even if unhappy, are appraised realistically. Their children, secure as infants, grow up to be well-adjusted socially and to have a realistic self-appraisal and a sense that separation, although often sad and painful, can be responded to positively. Secure mothers and secure children have a well- developed capacity for self-reflection and narrative ability, and convey a sense of coherence in their lives.
Insecure children, by contrast, especially if avoidant, tend to have mothers who found holding and physical contact difficult, who were unresponsive to their infant's needs and not well attuned to their rhythms. These mothers tended to be dismissing about their relationships with their parents and to be unable to tell a vivid or elaborated story of their own childhoods. As they grow up, avoidant children tend to be socially isolated, to show unprovoked outbursts of anger, to lack self-awareness and to be unable to tell a coherent story about themselves.
Are we seeing in these insecure children the roots of adult personality difficulty and neurosis? If so, what can we learn about the mental mechanisms that may underlie these disorders, and do they provide clues as to how psychotherapy might help to reverse them? We shall discuss in the next two chapters the parallels between avoidant strategies in infancy and some of the features of borderline personality disorder, and the possible links between phobic and dependency disorders in adults and patterns of ambivalent attachment in infancy. Our concern here is to try to conceptualise how maternal handling becomes internalised as infant psychology. In Fraiberg's (Fraiberg et al. 1975) telling metaphor: 'In every nursery there are ghosts. These are the visitors from the unremembered pasts of the parents; the uninvited guests at the christening. ' How do the parental ghosts get incorporated into the internal working models of the infant? Three inter-related ideas can be used to clarify this: avoidance of painful affect (Grossman and Grossman 1991), consistency and coherence of internal working models (Bretherton 1991a), and self-reflection (Fonagy 1991; Fonagy et al. 1991, 1992).
As we have seen in the previous chapter, Bowlby views the capacity to 'process' negative affect - to feel and resolve the pain of separation and loss - as a central mark of psychological health. Parents of insecure infants fail to respond appropriately to their infant's distress, either ignoring it (avoidants) or becoming over-
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involved, panicky and bogged down in it (ambivalents). It seems possible that because these parents have not been able to deal with or 'metabolise' (Bion 1978) their own distress they cannot cope with pain and anger in their infants and so the cycle is perpetuated. The infant is faced with parents who, due to their own internal conflicts or ego weakness, cannot hold (Winnicott 1971) the child's negative feelings of distress or fear of disintegration. The child is therefore forced to resort to primitive defense mechanisms in order to keep affects within manageable limits. Aggressive feelings may be repressed or split off, as in the avoidant child who does not react to his mother's absence but then shows overt aggression towards toys or siblings: or the insecure-ambivalent child who may show overcompliance based on 'identification with the aggressor'. Behavioural manifestations of these parent-child malattunements include such phenomena as gaze aversion, self-injury (such as head banging), freezing or fighting. They may also, as we shall consider further in Chapter 9, be related to such adult maladaptive behaviours as social avoidance, self-injurious behaviour such as wrist cutting, overdosing and substance abuse.
One can imagine continuities between infant physiological experience and psychological structures which evolve through childhood into adult life (see Figure 6. 1). From maternal consistency comes a sense of history: the reliability of the mother's response to the infant becomes the nucleus of autobiographical competence. From maternal holding comes the ability to hold one's self in one's own mind: the capacity for self-reflection, to conceive of oneself and others as having minds. The insensitivity and unresponsiveness of the mother of the insecure infant is not necessarily mean or abusive, but rather a failure to see the world from the baby's point of view, to 'take the baby's perspective' (Bretherton 1991a). The mother who cannot act as an 'auxiliary ego' for her child exposes him or her to inchoate and potentially overwhelming feelings when that child is faced, as will be inevitable (and in the case of an insecure mother to an excessive degree), with loss and separation anxiety.
Fonagy (Fonagy et al.
1991) sees coherence as a central feature of parents classified as Secure-autonomous on the AAI:
The coherence of the parent's perception of his past derives rom his unhindered capacity to observe his own mental
Figure 6. 1 The evolution of attachment patterns
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functioning. . . . This coherence is the precondition for the caregiver to be able to provide an 'expectable' or 'good enough' environment for the infant. . . . A child may be said to be secure in relation to a caregiver to the extent that his or her mental state will be appropriately reflected on and responded to accurately.
Without some sense of coherence and benignity towards oneself, self-reflection becomes distorted or even impossible, as the following case of borderline personality disorder illustrates.
'I hate myself'
Anna was a single parent in her mid-twenties. She became depressed and suicidal when her child was 6 months old. Her mother had been in hospital a lot when Anna was a small child because of TB, and at one point (when Anna was ten) had left the home for a while to live with another man. Despite this neglect Anna saw her mother as 'perfect', someone whose standards she could never match, and herself as hateful. She had two distinct 'selves': one competent, intelligent, well-organised, cheerful, compliant, pretty; the other dark, despairing, longing to die. In hospital at times she avoided eye-contact, secreted razor blades and frequently cut herself, was morose and monosyllabic, and would occasionally have outbursts of rage. At other times she was a model patient and collaborated enthusiastically with her therapeutic programme. She was discharged from hospital and started weekly analytic therapy, but once more became suicidal and was readmitted. She complained that she found psychotherapy very difficult because it meant that she had to think about herself. That entailed getting in touch with her self-hatred:
'Whenever I look into myself I come across the feeling that I want more than anything to die. I am forced to stay alive because of my daughter. Coming to talk to you reminds me of all the things I don't want to think about. '
Her wish to harm herself arose whenever she was faced with painful feelings of separation; for example, when she was on her own in the evenings. The origins of an almost unbridgeable split between her compliant and defiant selves, and the difficulty in reaching her real pain and hope could be seen in terms of insecure-
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avoidance, and the feeling that she had never felt securely held by her mother as a child, and was reminded of the anxiety and pain of this whenever she was on her own. She needed to be held by the hospital ward - sometimes actually - before she could begin to think about holding herself in mind in therapy, and to feel secure about her capacity to be a mother to her daughter. As suggested by Figure 6. 2, her mental state could be represented by a series of parallel concentric circles of holder and held.
Borderline patients like this provide adult examples of the insecure infant with a deficient holding environment, whose mother has been unable to reflect on and so metabolise her infant's feelings of pain on separation, who survives as best she can, using splitting, isolation and self-harm as ways of coping, and who, when she becomes a parent, is in great danger of perpetuating the cycle of insecurity. Ward staff and therapists may then counter- transferentially re-enact a repetition of the unresponsiveness and breaks in care that the patient experienced as a child. Thus Anna became passionately involved with one male nurse - paralleling her long-repressed desire to have an exclusive relationship with her mother - and did very well until he was transferred to another ward, whereupon she took a huge overdose of drugs.
Bowlby depicted healthy internal working models as subject to constant revision and change in the light of experience. Anna exemplified how in pathological mental states there is often a sense of repetitiousness and stuckness in therapy. Bretherton (1987) has speculated about why it might be that internal working models in insecure attachment are particularly resistant to change. She sees mental structures as organised hierarchically from low-level 'event-scripts' (Shank 1982), such as 'When I hurt myself my mother comes to comfort me', through intermediate generalisations like 'My mother is usually there when I need her', to basic assumptions: 'My mother is a loving person. I am lovable and loved. ' Insecure individuals not only may have negative core assumptions, but because communication between different levels of the hierarchy is distorted and restricted, may not be able to revise these models in the light of experience. Anna's basic assumption - 'I am hateful' - remained impervious to contrary evidence provided by the love of her boyfriend and the care of her therapists:
Figure 6. 2 Anna and the holding environment
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What seems to differentiate the Internal Working Models of secure and insecure individuals is in part their content, but also their internal organisation and relative consistency within and across hierarchical levels. . . . Reconstruction of working models cannot be achieved [simply] by 'lifting repression' or removing barriers which allow well-encoded, but hitherto inaccessible information to come into conscious awareness. Something much more akin to complete reorganisation and reinterpretation may be necessary.
(Bretherton 1991a)
THERAPEUTIC IMPLICATIONS
From the perspective of Attachment Theory the process of therapy will require the provision of a secure base, comprising reliability, responsiveness and the capacity to process negative affect, especially in relation to separation and loss. Out of this should emerge an individual with a greater capacity for self-reflection, increased coherence of mental structures and enhanced autobiographical competence. The implications of this for psychotherapy with adults will be considered in the next two chapters. It is beyond the scope of this book to consider the full implications of Attachment Theory for psychotherapy with children, and the reader's attention is drawn to the considerable literature on the subject (Belsky and Nezworski 1988; Greenberg et al. 1988). Three important areas of work will briefly be mentioned.
Lieberman and Paul (1988) have shown that a clinical classification of neurotic disturbance in pre-school children fits well with the categories suggested by Attachment Theory research. They found three basic groups of problematic behaviours: excessive danger seeking, such as wandering off unaccompanied in children whose mothers appeared to discount the attachment needs of their offspring; excessive danger fleeing with punitive mothers who discouraged exploration and illustrated the paradox of clinging to a punitive attachment figure; and children who were 'hypercompetent', equivalent to Bowlby's category of 'compulsive caregiving' (Bowlby 1980) in which there was role- reversal between children and their mothers and inhibition of expression of painful affect.
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Informed by attachment theory, several groups have attempted preventive psychotherapy with depressed mothers by working directly with the mother and her infant. Murray and Cooper (1992) describe one such case.
'Uppie . . . uppie'
Following a puerperal depression, Joan had felt unable to get emotionally close to her 18-month-old daughter Sophie, and was frightened that the pattern of distance and lack of trust which characterised her relationship with her own mother was repeating itself. Tested on the Strange Situation, Sophie showed a typical pattern of insecure-avoidance. In the course of brief exploratory- supportive therapy in which Sophie and Joan were seen together, their relationship changed dramatically. In place of distant watchfulness, Sophie began to approach her mother, asking to be picked up and cuddled, saying 'Uppie, uppie', and was responded to with warmth and affection. At the same time negative feelings became less problematic for both of them. When Sophie cried or was difficult and rejecting, Joan could tolerate this without feeling guilty, and could also allow herself to become irritable with her daughter at times. In parallel with these changes Joan reported an improvement in her relationship with her own mother: here too she could be both affectionate and cross instead of, as before, maintaining a cool distance. At termination, Sophie's re-test on the Strange Situation now showed a pattern of secure attachment. In place of a rigid and restricted pattern of relating, each was able to respond to the other in a more fluid and spontaneous way. This movement from inflexibility towards 'give' and play illustrates Winnicott's (1965) well-known dictum that the essence of psychotherapy is learning to play.
In view of the increasing numbers of adult psychotherapy patients who report sexual and/or physical abuse in childhood, mention must also be made of studies which have approached familial abuse from the perspective of Attachment Theory. 'High risk' (that is, low socio-economic status) parents do not have disproportionate numbers of insecure children. The A/B/C ratios remain roughly the same: B, 65 per cent; A, 20 per cent; C, 15 per cent. The proportion of A/C families rises sharply among mothers with major depressive illness, and in families where there is proven sexual or physical abuse. With depressed mothers, 40 per cent of
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children were insecure-avoidant, and in abusive families 50 per cent are avoidant and 30 per cent disorganised, with only 10 per cent classified as secure (Belsky and Nezworsky 1988). The apparent compliance and conformity sometimes seen in adult patients who have been abused can be understood in the light of Crittenden's (1988) comment that
Attachment Theory proposed that the maintenance of affectional bonds . . . is essential to the survival of the human species and a compelling individual need. . . . Those people who are most at risk for destroying their love relationships altogether devote the most intense effort towards maintaining the semblance of bonds; inept mothers and their children scrap and feud; mildly abusing mothers and their children are hostile and difficult; but many severely maltreating mothers do not dare challenge the durability of their relationships . . . it is as though they fear that a simple dispute could become an uncontrollable attack on the relationship.
CONCLUSION
Bowlby's grafting of the experimental methods of ethology to the insight of psychoanalysis has born rich fruit. The research we have surveyed in this chapter has begun to lay bare some of the relational elements which provide the foundations of psychological health: a sense of security, of efficacy, of being loved and having the capacity to love, of being a person in the world like others and yet with one's own unique biographical trajectory, of being able to withstand the failures, losses and disappointments that are the inevitable consequence of the 'thousand natural shocks that flesh is heir to'. We have learned about some of the ingredients that make up good parenting: responsiveness, attunement, holding. We turn now to the implications of these findings for psychotherapy, and to further exploration of the relationship - at times avoidant, at times ambivalent - between Attachment Theory and psychoanalysis, in the hope of finding a more secure and coherent synthesis.
Part III Implications
Chapter 7
Bowlby and the inner world: Attachment Theory and psychoanalysis
[The] early formulations of psychoanalytic theory were strongly influenced by the physiology of the day . . . cast in terms of the individual organism, its energies and drives, with only marginal reference to relationships. Yet, by contrast, the principal feature of the innovative technique for treating patients that Freud introduced is to focus attention on the relationships patients make with their therapist. From the start, therefore, there was a yawning gulf between the phenomena with which the therapist was confronted, and the theory that had been advanced to account for them.
(Bowlby 1990)
Bowlby was primarily a theorist rather than a therapist. Although trained psychoanalytically, and active in the Psycho-Analytical Society from the late 1930s until the late 1950s, where he held high office, he saw himself mainly as a researcher and administrator. Case reports and clinical illustrations are to be found throughout his writings, but, with the exception of his earliest papers, these are almost all based on the work of colleagues or on published articles by other authors. Dreams are nowhere to be found in his work, and he is, for the most part, concerned with observable behaviour rather than the inner world. Nevertheless, Attachment Theory is a child of psychoanalysis and has much to contribute to the theory and practice of psychotherapy. Towards the end of his career Bowlby (1991)
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wrote, 'my theoretical work has always been directed primarily to my colleagues in the International [Psychoanalytical] Association'. The aim of this chapter is to consider in some detail the relationship between Attachment Theory, psychoanalysis and contemporary psychoanalytic psychotherapy.
Bowlby's reservations about psychoanalysis come under four main headings: its neglect of real experience and environmental influence in favour of overemphasis on autonomous phantasy; an atmosphere of dogmatism inimical to scientific enquiry; an outmoded metapsychology; and a lack of experimental observation to underpin its unbridled theorising. All of these objections may seem to the contemporary observer somewhat overstated, and we must first place them in an historical context.
HISTORY: BRITISH PSYCHOANALYSIS 1935-60
The atmosphere in the British Psycho-Analytical Society when Bowlby started training in the mid-1930s was one of ferment and controversy. The heady excitement of a new science of mind that went straight to the heart of twentieth century men's and women's discontents seemed to have generated a hotbed of intrigue, back-biting, gossip and jockeying for position. The climate resembled less that of a scientific society than of a family in which a patriarch was nearing the end of his life with the terms of his inheritance still undecided.
Ernest Jones had invited Melanie Klein to practise in London and had entrusted his own two children to her for child analysis based on her new technique of play therapy. Until the advent of Klein, the focus of analytical work was predominantly the Oedipus complex. She insisted on the importance and the analysability of much earlier stages of development, and in particular on the phantasies and anxieties of the infant in its first two years of life. As we saw in Chapter 1, Freud tended to regard Klein's views with some disfavour (Steiner 1985), especially as her ideas about child analysis differed from those of his daughter Anna, who saw splitting and other primitive defence mechanisms such as projective identification proposed by Klein as belonging to a much later stage of development.
At the time of the arrival of Freud and Anna in London in the late 1930s the British Society comprised a group of highly talented and intelligent people, including James Strachey, Edward Glover, Sylvia Payne, Melanie Klein (Bowlby's supervisor) and Joan Riviere (Bowlby's analyst). A leadership struggle broke out with
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an increasing schism between the Kleinian camp, who were accused of dogmatism and attempts to win students exclusively onto their side, and the more orthodox Freudians, represented by Anna and her followers, together with a third group, who remained non-aligned. Eventually, in 1944, a compromise was reached with the 'gentleman's agreement' (in fact made between three women, Klein, Payne and Anna Freud) between the parties to form separate 'streams' of training and scientific discussion, while remaining united within one society.
Although Bowlby's organisational and intellectual talents were recognised early on - he was appointed Training Secretary of the Society in 1944 (Melanie Klein opposed this on the grounds that he was not a Training Analyst) - he was somewhat at variance with the mainstream of the analytic milieu. His strong commitment to the scientific method, his quintessential Britishness and reserve, his decision to work in child guidance clinics rather than in private practice, set him apart. These very qualities, as well as the fact that he was the son of a famous surgeon, may also have given him the credibility with the medical establishment that was needed for his successful popularisation of psychoanalytic ideas about the importance of infancy, and the mother-child relationship, as a determinant of later mental health.
From early in his psychoanalytic career Bowlby had had misgivings about the way in which analysts downplayed the importance of the environment in the origins of psychological disturbance. Although Freud has been accused of a deliberate and cowardly retreat from his original hypotheses about the adverse effects of childhood seduction (Masson 1985), there is no doubt that he continued to believe that childhood trauma was important, but as the pioneer of a new 'science' he emphasised the primacy of the inner world as the proper domain of psychoanalytic discourse, and this lead was certainly adhered to by his followers. Bowlby writes:
During . . . 1936-39 I was slowly waking up to the fact that my ideas were developing in a direction very different from those that were accepted truths in the British Psycho-Analytical Society . . . under the influence of Ernest Jones and Melanie Klein it was held that an analyst should concern himself only with the patient's internal world and that to give attention to his real life experiences could only divert attention from what really matters. My experiences in the Child Guidance Clinic . .
130 Imlications
. were leading me to an opposite conclusion . . . that one can only understand a person's internal world if one can see how [it] has come to be constructed from the real-life events to which he has been exposed.
(Bowlby 1991; Rayner 1992)
A marked copy of a paper by Bowlby's analyst Joan Riviere contains the following passage:
Psychoanalysis is Freud's discovery of what goes on in the imagination . . . it has no concern with anything else, it is not concerned with the real world . . . it is concerned simply and solely with the imaginings of the childish mind.
(Quoted in Rayner 1992)
In the margin Bowlby has pencilled 'Role of the environment = zero' (Rayner 1992). Bowlby was particularly distressed when the mother of his first training patient in child analysis, a hyperactive little boy of three, was admitted to mental hospital:
When I reported this to Melanie Klein [his supervisor], however, her only concern seemed to be that, since it was no longer possible for me to continue the boy's analysis, another patient must be found for me. The probability that the boy's behaviour was a reaction to the way his mother treated him seemed altogether to escape her.
(Bowlby 1991)
Bowlby consistently stressed the range of environmental traumata to which a developing child can be exposed: actual separations and disruptions in care; threats of separation or suicide by parents; being unwanted, or the 'wrong' sex; suppression of the true facts about parentage (for example, grandfather or uncle the true father, or sister the true mother); role reversal and the 'parentification' of children. His views have been thoroughly vindicated by the recent disclosure of the extent of physical and sexual abuse of children. The evidence that more subtle forms of environmental failure such as parental unresponsiveness and mis-attunement underlie childhood and probably adult psychopathology has been reviewed in the previous chapter. These findings make the polarisation between Bowlby's characterisation of the Kleinians as wholly uninterested in the environment and exclusively concerned with phantasy, and his own insistence on the primacy of
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environmental failure rather artificial. The Kleinian account is a phenomenological description of mental states found in adult patients, particularly those with borderline pathology, inferring from these what may have gone on in the minds of infants and small children. The Kleinian account contains no clear causal model to account for the phenomena she describes. Bowlby and the post-Bowlbians offer the outlines of an explanation of how such pathological states come about. They suggest that the capacity to phantasise and to symbolise, as opposed to resorting to defensive enactments of unmanageable feelings, is itself environmentally sensitive. Parents who can contain and attune to their children have children who can put their feelings into words and who are able to resolve conflict. Those who cannot contain and attune are more likely to have children who are at risk of dealing with their feelings by splitting and projective identification, and so being afflicted by a sense of emptiness and meaninglessness. It is worth noting that Klein, like Freud, assumes that there may be constitutional differences between infants, a point which Bowlby tends to overlook. Westen (1990) has suggested that some babies may have reduced inborn capacities for self- soothing, which would make them more vulnerable to parental deficiencies in containing and calming.
A second area of difficulty about psychoanalysis for Bowlby was its atmosphere of dogmatism and authoritarianism. Peterfreund (1983), who is approvingly cited by Bowlby in several places, decries what he calls the 'stereotyped', dogmatic, 'alogarithmic' approach of traditional psychoanalytic formulation and interpretation. He compares this with the 'heuristic' approach which he and Bowlby advocate, in which patient and therapist find things out for themselves rather than imitating Talmudic scholars burrowing in the obscure texts of the psychoanalytic testament. There is no doubt that at its worst psychoanalysis can degenerate into a mouthing of cliche? d formulas by an omniscient analyst who, faced with the pain and complexity of suffering, offers some certainty, however ill-founded, to a confused patient who has no choice but to grasp at straws. The relentless interpretation of the transference may hypnotically open the patient up to layers of regression and dependency which make such interpretations self-fulfilling prophecies. There has been a move towards a much more tentative approach to interpretation in contemporary psychoanalysis (Casement 1985), in which Keats's 'negative capability' - the capacity to allow oneself to be 'in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason' - is valued, and indeed is seen as the hallmark of the 'depressive position' with its emphasis on compromise and reconciliation
132 Imlications
rather than splitting and false certainties. Bowlby writes that
I was dissatisfied with much of the [psychoanalytic] theory . . . being a somewhat arrogant young man . . . I was in no mood to accept dogmatic teaching. My analyst was not altogether happy with my critical attitude and complained on one occasion that I would take nothing on trust and was trying to think everything out from scratch, which I was certainly committed to doing.
(Bowlby 1991)
Bowlby's re-thinking of psychoanalytic metapsychology and terminology has been discussed in the preceding three chapters. Attachment Theory is perhaps best seen as a variant of Object-Relations Theory, using updated terminology and informed by neo-Darwinism. Attachment comprises a distinct motivational system - which includes drive, affect, cognition and behaviour - that parallels and complements sexuality. The main differences between classical Freudian theory, the Object-Relations Theory of Klein, Fairbairn and Winnicott, and Attachment Theory are summarised in Table 7. 1. For Bowlby the important issue is not, as the orthodox Freudians thought, sex, but security. Attachment is primary, not a derivative of orality. The organism is not an isolated drive-driven creature in search of an object on whom to discharge his accumulated tension, but a person relating to other persons. Homeostatic and other cybernetic control systems govern his behaviour, just as they do that of other mammals. His relationship to the world is determined not just by unconscious phantasy but also by internal working models which include affective, cognitive and behavioural elements. Aggression is a response to frustration and loss, not an intrinsic property of an individual dominated by the death instinct.
Bowlby's fourth cavil at psychoanalysis was its neglect of direct observation of normal and abnormal children. He felt that reconstructions based on childhood recollections of disturbed patients, while valuable in themselves, did not qualify as a scientific account of what really goes on in real children. He therefore set out to study systematically the effects of separating infants and
Table 7. 1 Classical, Object-Relations and Attachment Theories compared


136 Imlications
children from their parents, and it was on the basis of those findings that Attachment Theory was born.
BOWLBY AND THE POST-FREUDIANS: THE POST-WAR PERIOD
To continue with our historical account, Bowlby was of course not alone in his dissatisfaction with the state of psychoanalysis in the 1940s and early fifties. During the post-war period several divergent responses can be found within psychoanalysis and psychotherapy in response to the difficulties - dogmatism, obsolete metapsychology and anti- empiricism - with which Bowlby was struggling. The first was the development of Object-Relations Theory, epitomised by the work of Winnicott, Fairbairn and Balint, all of whom were influenced by the Kleinian emphasis on the early infant- mother relationship, but, taking the decisive step of abandoning drive theory altogether, posited relationships as primary. Mahler's (1975) direct observations of mothers and infants from a psychoanalytic perspective combined object relations with a degree of empiricism.
A quite different tack was to reject the pseudo-scientific determinism of classical Freudianism altogether, seeing psychoanalysis more as a hermeneutic discipline concerned with meanings rather than mechanisms and emphasising the importance of the creative imagination and spontaneity as the wellspring of the psychoanalytic process (Rycroft 1985). Meanwhile, neo-Kleinian developments concentrated on delving deeper and deeper into the mysteries of the infant- mother relationship in the early stages of life and relating these to the findings of psychoanalysis with psychotic patients (Bion 1978). Finally, there were moves away from the psychoanalytic paradigm altogether, adopting either a family systems approach derived from cybernetics and anthropology (Bateson 1973), or a 'cognitive' approach, based on Piaget and Kelly, in which the logical operations of the mind and the way in which they are organised hierarchically form the basis of psychotherapeutic theory and practice (Beck et al. 1979).
Bowlby and the inner world 137
Bowlby and Winnicott
Bowlby as a researcher responded to the problems of the psychoanalytic paradigm by moving in the direction of observable behaviour. Attachment, whether secure or insecure, avoidant or ambivalent, can be observed, rated, measured, correlated. By basing his ideas on ethology Bowlby sidestepped the dehumanisation and absurdities of stimulus- response behaviourism, while remaining within the framework of conventional science. Winnicott, an outstanding clinician but an elusive theorist, was wrestling with the same problems but from the perspective of the inner world, developing in his idiosyncratic but highly original way a language of experience directly applicable to the therapeutic situation.
Winnicott and Bowlby had much in common. Both were very 'English' in their background and outlook, in contrast to the European/ Jewish/Celtic atmosphere of the Psycho-Analytical Society. Both had had a Cambridge scientific education and were deeply influenced by Darwin. They shared an analyst, Joan Riviere, who, despite her later Kleinian orthodoxy, was firmly interpersonal in her philosophy. With an echo of John Donne, she wrote:
There is no such thing as a single human being, pure and simple, unmixed with other human beings. Each personality is a world in himself, a company of many.