Attachment is defined as the lifelong need human beings have for affectionate ties with significant other human beings. It is a biological necessity for Human Beings to have a secure attachment relationship. The development of the brain and emotional regulation capacities depends on this attachment from late pregnancy to at least 2 years of age. Infants who have been responded to sensitivelyand held frequently and affectionately during the early months, cry less towards the end of the first year and are able to play happily and explore their environment.
Attachment can be defined as the lifelong need human beings have for affectionate ties with significant other human beings (Ainsworth, 1982; 1989). Harlow (Harlow & Zimmerman, 1959) in his research with rhesus monkeys demonstrated that attachment is not dependent on the need for food. Attachment theory is based on clinical enquiry, ethological evidence and scientific research (Berk, 2003), in contrast to Freud’s theory and classical object relations theory, which are based on drive theories of human nature (Corey, 1996). Although much of the research on attachment has focused on infants and children, attachment theory is also applicable to adults in a psychodynamic framework, as attachment patterns tend to remain stable through to adulthood (Hesse 1991; Fonagy, 1991).
Domains of Attachment Theory and Therapy
Attachment theory was initiated by the work of Bowlby (1969), who, inspired by ethological research on imprinting behaviour (Lorenz, 1952) and critical periods (Katz, 1999), argued that attachment to a primary caregiver is a biological need essential for the survival of the species by ensuring safety and developmental maturation. It is a biological necessity for Human Beings to have a secure attachment relationship. The development of the brain and emotional regulation capacities depends on this attachment from late pregnancy to at least 2 years of age (Schore, 2001). Attachment, according to both Schore (2001) and Bowlby (1969), is adaptive, and optimal development occurs in an environment of safety where emotional synchrony, resonance and attachment communications can occur between an infant and his caregiver/mother. This maternal infant mutuality encourages social responsiveness thus enhancing the infant’s future potential for survival and the quality of future engagement with other human beings.
Holmes (2001) has identified six domains across which attachment relations occur, described as follows:
1. Secure Base and Attachment Styles
Infant behaviour is characterized by seeking closeness to the caregiver. When this behaviour does not elicit caregiving responses, behaviour follows a specific sequence of ‘protest-despair-detachment’. If the attachment figure(mother) reestablishes contact, protest will be interrupted and closeness sought with the caregiver. A mother/caregiver regulates the interpersonal experiences of her infant by being responsive, assisting the infant to modulate stress when ‘ruptures’ in the attachment bond occur, such as when a mother is separated or temporarily out of synchrony with the infant’s needs.
Mary Ainsworth and colleagues (1978) designed a study to measure the quality of attachment between young children and their mothers (The Strange Situation) and identified 3 attachment patterns. This was supplemented by a 4th pattern in subsequent research (Main & Solomon 1999).
1.1 Secure Attachment: A secure infant will explore in the presence of parent, be visibly and audibly upset when separation occurs and will reinitiate and maintain contact when parent returns, followed by resuming play.
1.2 Avoidant Attachment: The infant fails to cry on separation from parent and ignores parent after reunion. Affect seems flat and contact with parent is not actively sought.
1.3 Resistant/Ambivalent Attachment: Infants may fail to explore before separation occurs, and display anger and aggressive responses when the parent returns after separation. The infant will not resume play.
1.4 Disorganised/Disoriented Attachment: Contradictory behaviours such as gaze aversion while crying and clinging or flat affect while approaching parent.
The capacity to separate without undue anxiety in the absence of an attachment figure is a signature of secure attachment. People with Insecure attachment styles do not cope as well with loss or separation and this may hamper the open responsiveness required both in marital relationships and mother-infant dyads. Insecure attachment models may be modified by new interactional experiences that facilitate safety and promote trust (Johnson & Greenberg 1995) and can be applied through community intervention programmes at the maternal infant dyad interface, such as the Perinatal Mental Health Service at Mowbray Maternity Hospital, South Africa. Similarly, in therapy, a therapist will attempt to create a safe milieu by being attuned and responsive to the client’s needs, but will also hold the space between them, modulating affective behaviour.
2. Exploration and Play
Ainsworth (1974) commented that infants who have been responded to sensitively and held frequently and affectionately during the early months, cry less towards the end of the first year and are able to play happily and explore their environment. As Schore(2001) states, “Attachment is not just the establishment of security after a dysregulating experience and a stressful negative state, it is also the interactive amplification of positive affects, as in play states…..creates ….a positively charged curiosity that fuels the burgeoning self’s exploration of novel socioemotional and physical environments”.
In the context of any attachment relationship, the capacity to enjoy relating to or playing with someone is indicative of healthy secure relationship. A mother who can play with her infant is both giving and receiving pleasure in the reciprocity of the interaction. Similarly, in sexual relationships, the ability to interact as a companion, to give and receive mutual pleasure without losing one’s sense of self forms a basis for secure attachment and interdependence. In the therapy situation, the pleasure of having a secure base is interspersed with exploring the real world outside of therapy.
3. Protest and Anger
Anger is a response to separation and can become despair if the attachment figure is not restored. In fact, an infant will exhibit protest–despair behaviour from birth if separated from the maternal milieu or habitat (Alberts, 1994; Christenson at al, 1995). Anger or hostility towards a caregiver, according to Bowlby (1998:296), is best understood as a response to frustration, but because it is repressed or redirected the ‘balance of responses towards an attachment figure can become greatly distorted and tangled’. Bowlby (1973) observed that anger is a frequent response to loss and goes so far as to say, “the most violently angry and dysfunctional responses of all are elicited in children and adolescents who not only experience repeated separations but are constantly subjected to the threat of being abandoned”. When threats are used to discipline children it also induces anger at the caregiver, which is suppressed so as not to disrupt the relationship (adaptation). In psychoanalytic language, this act of repressing may become ‘secure base’ if the attachment figure is repeatedly threatening. A client in therapy may bring with them their unconscious childhood attachment style, both a clue to the client’s early history and an opportunity through transference and counter transference for the therapist to address the client’s wound. The therapeutic relationship provides an opportunity for the client to find and name their feelings of protest or despair with respect to losses in the past and/or present and to discover and repair what Balint (1979) calls the “basic fault” in the context of a safe relationship.
Robertson and Bowlby (1952) identified three phases of separation response: protest related to separation anxiety, despair (related to grief and mourning) and detachment (related to defence mechanisms, especially repression). Bowlby (1960) believed that when a caregiver continues to be unavailable to the infant, or when the succession of primary the attachment figure is too frequent, protest-despair responses will result in detachment and may affect the infant’s ability to form interdependent and caring relationships in life. Bowlby and another colleague (Bowlby & Parkes, 1970) categorized four phases adults experience in the grieving process: a) numbness, b) yearning and protest, c) disorganization and despair, and d) repair and reorganization. Remembering and grieving losses that occurred in the past is a crucial part of any therapeutic process.
5. Internal Working Models
The concept of ‘internal working models’ akin to cybernetic information systems infers pragmatism and yet may be likened to the use of schemata in cognitive therapy or the introjection of an object intrapsychically in object relations psychoanalysis. Internal working models of the self and attachment figures are acquired through interactions with attachment figures. Bowlby (1973) proposed that firstly, when a person is confident that an attachment figure is available, he is less prone to fear responses, that secondly, this confidence is established throughout childhood, particularly in infancy and once established remains stable throughout life, and thirdly that styles of relating to others are accurate reflections of experiences in early relationships.
If the attachment figure is responsive and protective while at the same time respecting the need to grow and explore the environment, the infant will develop an internal working model of self as deserving and dependable. However, if the caregiver/parent rejects or ignores calls for comfort and attention and prohibits exploratory activity, the infant is more likely to construct an internal working model of himself as unworthy and ineffectual.
6. Reflexivity and narrative competence
The Adult Attachment Interview (AAI) devised by Mary Main (Main & Goldwyn, 1995) is a psychotherapeutic questionnaire that assesses the style and form of linguistic responses to attachment related questions. It reveals that how people narrate their experiences indicates their attachment style, and that these styles correspond to the attachment styles identified in the Strange Situation by Ainsworth (1974).
A) Secure adults speak coherently, place a high value on attachment and describe experiences and relationships consistently, regardless of whether they were satisfying or not. B) Ambivalent or preoccupied adults recount their past experiences in an emotional and haphazard way i.e. there is no clear or coherent picture. C) An avoidant adult may not remember, dismisses, normalizes and generalizes descriptions of attachment relationships and is not coherent. D) A disorganized adult will lose track of coherent thoughts or feelings about loss or abuse, and may lapse into prolonged silence or monologues. Disorganized infants or adults may also exhibit any of the above three attachment style tendencies.
Holmes (2001) states ‘therapy is an in vivo experience in which the patient learns to become self-reflexive”. The ability of clients to reflect on their narratives, their feelings and thoughts in a meta-cognitive way can be encouraged and developed in the therapy process of deconstruction and reconstruction of narratives. By enlarging the client’s capacity to rework internal working models he may be enabled to confound, change and reconstruct his outdated narrative.
The Therapeutic Process
The overall goal in attachment therapy is to reappraise internal working models of the self in relation to attachment figures. This may be difficult if parents have not allowed children to view the parent’s own working models neither allowed their children to review their own working models (Bowlby, 1988). A client in therapy may bring these rigid internal models of attachment to therapy and impose these models on his relationship with the therapist (transference in psychoanalytic language). Clients with ambivalent attachment patterns may feel hostile towards the therapist (transference) in the course of therapy and confronting and containing these feelings without destroying the relationship is part of the therapeutic task. It is important for the therapist to be aware of her own feelings (counter-transference), to utilize these creatively in navigating the relationship and explore with the client a means of reworking internal working models.
An important function of a therapist in the attachment theory framework is to provide a secure base for the client. Forming a therapeutic alliance, creating a relationship of trust, listening and responding attentively, steadying the clients displaced feelings are all characteristics of providing a safe, secure space. It is in this context that an insecurely attached person may be willing to risk replacing avoidant, ambivalent or disorganized patterns of relating and reconstruct a secure base narrative (Holmes 2001). The therapist aims to behave differently to the client’s previous attachment figures, create a holding environment for the clients ‘unsafe’ feelings to emerge, so that intimacy, exploration and ultimately autonomy can occur. The pattern of regular appointments coupled with a secure-attachment base will help the client repair ‘ruptures of the bond’ and learn to modulate their own affective responses.
These therapeutic aims may call on an eclectic mix of techniques, such as Rogerian person centered listening skills (Corey, 2001), analysis of dreams , free association and working with feelings to access, validate, reprocess and restructure responses, and reframe and restructure her internal working models of disorganized attachment. Cognitive and/or behavioural injunctions like keeping a diary, and involving the client in the formal structure of therapy will help to encourage trust and promote change.
Multicultural issues may arise and therapists need to be aware of how their own cultural background influences their perceptions. Strategies may have to be reappraised and it is important to try and share the worldview of multi-cultural clients (Arredondo, 1998), ascertain what their expectations for change are and find an intervention for alleviating client distress (Fischer et al, 1998).
Peggy McIntosh in Berzoff (1996) points out that white feminist scholars assume their own experiences are universal, normative and representative. While African women appreciate being listended to, they may not wish to explore the past, and wante practical solutions to their problems. Whereas Western ideals are rooted in individualism and equality between the sexes, urbanized African families are still rooted in African family networks. A pregnant woman may need to draw on the support of her own family networks and therefore have to operate within her cultural constraints.
Classical psychoanalysis is prey to much feminist critique in that it does not address how cultural and gender issues affect women in society and how women’s mental health is a product of their cultural milieu (Ivey, Ivey, Simek-Morgan, (1997). The role of fathers is downplayed in early attachment literature. Secure attachment is also predicted by the sensitive care giving of fathers and strengthens the more they spend time with their babies (Van Ilzendoorn & De Wolff, 1997). Although attachment may have different meanings in different cultures (Grossman et al, 1985), despite cultural variations, secure attachment is still the most common and preferred pattern in all societies studied to date (Van Ilzendoorn & Sagi, 1999; Posada et al., 1995) and Attachment therapy may well be universally applicable.
As Bowlby ((1940:23) has aptly stated, when a parent, in therapy, is helped to recognize their own childhood feelings and is accepted and understood, they are able to become increasingly tolerant towards the same feelings in their child.
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© Marianne Littlejohn