doing&what&comes&naturally:&how& … ·...
TRANSCRIPT
Doing what comes naturally: how attachment theory informs
psychotherapy
Prof Jeremy Holmes
University of Exeter
UK
Starting point
‘Theory-‐prac<ce gap’ in psychoanaly<c psychotherapy
What are psychotherapy’s ‘ac<ve ingredients’? (c.f. Darwin)
Can there be a GTE -‐-‐ meta-‐theory – ‘deep grammar’ for psychotherapy?
John Bowlby
Attachment Theory and psa
Empirical basis
Connec<on with other disciples, esp ethology, scien<fic child observa<on
security v sexuality (hymen = limen + eros)
Makes clear dis<nc<on between healthy, vulnerable, and pathological developmental pathways
All effective therapies…
1. Therapeu<c alliance/rela<onship (‘subject’)
2. Meaning/explanatory framework (‘verb’)
3. Change promo<on (‘object’)
(Castonguay & Beutler 2006)
1: Therapeutic relationship (Holding, containing)
1. Space
2. Mirroring: Con<ngency & Marking
3. A^achment styles
4. Goal-‐corrected Empathic A^unement (GCEA)
5. Rupture and repair
The red dot
Secure relationships
Therapy as specialisa<on of everyday in<mate rela<onships (parent/child, spousal, ?friendship/sibling):
Sensi<vity/mentalising
Mastery – holding – boundary – crea<ng a space
Mirroring: Winnicott & Gergely
Mother’s face as the mirror in which the child first finds him/herself
Con,ngency: the capacity to hold back and wait
Marking: slight exaggera<on: !! – message is ‘this is my reflec,on of your being/feeling, not my own you’re hearing/seeing’
Typical therapist ‘marking’ moves
“you did what?!”
“that sounds painful”
“ouch!!”
“it sounds like you might be feeling pre=y sad right now”
“I wonder if there isn’t a lot of rage underneath all this”.
Dora: ‘what she said took me aback’ (Freud 1905)
Mirroring (Wright)
The child finds her/himself in the form of the maternal response; cross-‐modal a^unement (Stern) leads to…
A lexicon of experience, bodily sensa<on, representa<ons, in which feelings are embodied…
Free (secure), restricted (insecure organised) or absent (insecure disorganised)
Exploring In Security
Mutual incompa<bility of a=achment behaviour and explora,on
Empathic response + affect regula,on assuages a^achment behaviours and ac<vates explora<on
‘vitality affects’ evidence of exploratory stance: eyes, voice tone, ‘energy’ levels
Explora<on associated with sense of mastery and competence (c.f. Slade’s mothers)
Misattunement: rupture and repair (Safran & Muran)
Normal, ‘good’, securely a^ached, mentalising, mothers – mis-‐a^une 60% of the <me (Tronic)!
But are able to re-‐establish emo,onal link
BUT via self-‐monitoring/mentalising, know they’re gemng it wrong and so can self-‐correct
Duration of Looking at Self During Three Phases of Modified Still Face Procedure
(Gergely, Fonagy, Koos, et al., 2004)
% looking at self
F(interaction)=6.90, df=2,137, p<.0001
Duration of Looking at Self During Three Phases of Modified Still Face Procedure
% looking at self
F(interaction)=12.00, df=2,137, p<.0001 (Gergely, Fonagy, Koos, et al., 2004)
‘Enactment’
Therapists ‘get it wrong’ too…
either in the micro-‐moments of the session (too much silence; too li^le; comments that go awry; failure to pick up on p’s emo<onal state, etc)
or macro (e.g. double booking, being late etc)
In ways that reflect the pa<ent’s (and their own) psychodynamics i.e. enactments
Safran
Repairing weakened alliance predicts stronger alliance and be=er outcome
Process model: a) a^ending to ‘rupture markers’ b) exploring experience c) exploring avoidance d) exploring underlying wish
Importance of therapist non-‐defensiveness
Grossmans: role of mother and father
Maternal sensi<vity (empathy, soothing, responsiveness), ‘mind-‐mindedness’ (Miens)
Paternal facilita<on (“you can do it, and I will protect you as you do so”); ‘zone of proximal development’
Combined parent scores best predictor of secure representa<on in early adulthood
2: Meaning
Many types of meaning: medical, cogni<ve, interpersonal, unconscious etc
Evidence does not priviledge one over the others
AT suggests ‘polysemy’ is mark of secure a^achment
Mentalising: the process by which… (Bateman & Fonagy 2004)
an individual implicitly and explicitly interprets the ac,ons of himself and others as meaningful on the basis of inten,onal mental states such as personal desires, needs, feelings, beliefs and reasons
Mentalising:
To see ourselves from the outside and others from the inside.
Burns: ‘o wad som pow’r the gipie gie us, to see oursl’es as ithers see us’.
Mentalising not purely ‘mental’
Starts with the body
Thinking about feeling; feeling about thinking:
Spinoza/Boulanger: ‘the ideal musician should think with the heart and feel with the intellect…’
Why mentalising?
Captures self-‐in-‐rela<on-‐to-‐others
Biological roots suggest associated with fitness/health (c.f. primate studies)
Deficient (associated high arousal levels) highly relevant to ‘complex cases’
Learned rela<onal skill -‐ developmentally & in therapy
Measuring mentalising: ‘reflective function’ (RF in AAI)
High RF scores in ‘pregnant’ parents predicts infant security in Strange Situa<on
RF predicts ‘fluid-‐autonomous’ on the AAI, protec<ve against childhood neglect or trauma
Poor mentalising in mothers of ‘disorganised’ infants (?risk factor for BPD)
Pre/Non-‐mentalising states of mind
Psychic equivalence mode: outer world = inner world, (‘what I feel, is’) ?c.f. ‘excessive’ Projec<ve Iden<fica<on
Pretend mode: decoupling of self from outer world (‘I can make the world as I like…’) ?c.f. Psychic retreats
Teleological stance: denial of inten<ons, seeing only external connec<ons and consequences (‘if I cut myself, drink etc, I’ll surely feel be^er’) ?c.f. ‘a^acks on linking’
Misuses of mentalising
Pseudo-‐mentalising, e.g. intellectual rather than emo<onal understanding; failure to acknowledge opacity of inner world; ‘going round in circles’ (c.f. hyperac<va<ng a^achment styles)
Using mentalising to manipulate or abuse: mild: interpreta<ons in marital arguments); severe: grooming’
Conditions fostering mentalising: 1: lowered arousal
Subliminal posi<ve cues override insecure a^achment pa^erns (Miculincer & Shaver)
Neutrality = non-‐controlling, hopeful, taking seriously, valida<ng
? introjec<on of benign, less harsh superego
The frog in the bucket
Conditions fostering mentalising 2: triangulation
Therapy as in vitro mentalising arena: playing the ‘in<macy game’ ‘hand up’
Therapist and client together ‘triangulate’ the object – the client’s feelings
Triangula<on = poin<ng, naming, storying, makes/creates ‘present unconscious’ conscious
Mindfulness and mentalising
Both based on percep<on/reality gap
Both seen as learned skills
Both aim to lower arousal
Both improve therapeu<c effec<veness
Mindfulness formally taught
Mentalising informally integral to therapeu<c rela<onship
3: Promoting change
Fostering mentalising skills
Paradox and benign binds
Paradox/ambiguity
Therapist enters pa<ents world (idiolect)
but does not conform to it, and
since s(he) can neither expel nor control therapist
this catalyses change since pa<ent has to alter rela<onal world
(Strachey, Lear)
Therapy as a ‘benign bind’
Therapist confounds expecta<ons: offers no solu<ons/advice/prescrip<ons – p. has no choice but to find them for him/herself
Therapist playfully offers both ‘real’ and ‘unreal’ rela<onship: p. develops a stronger reality-‐phantasy barrier (esp in PD)
Paradox needed where common sense fails, ‘outwimng’/circumven<ng defences, c.f. arm paralysis
‘Benign binds’
Bateson & the double bind
DB revived by Main in her model of Disorganised a^achment as an approach/avoidance dilemma
Approach/avoidance dilemmas in Borderline func<on: in<macy is what is both most desired and most feared: ‘flips’ from deac<va<on to hyperac<va<on.
Linehan’s change/no change message for Borderline clients
alcohol
Case history
Single wo mid-‐40s, BPD, Alcohol
5 yrs Rx – x1/week, couch
Own apartment, career, no self harm, but s<ll drinking, s<ll v lonely
Goes to Buddhist retreat during analy<c break
During medita<on ‘sees’ self pouring ‘poison’ down throat
Case history cont
Aper break – drinking again. Explains an<dote to loneliness
Th: ‘What would it be like if the drunk part of you were to come to sessions?’
P: ‘Oh I might ‘come on’ to you’…
Th: ‘So whatever I did would be wrong: responding would be abusive like your step-‐father; not responding, un-‐mirroring like your depressed mother’
Case history continued
P: ‘maybe I just want to be validated and accepted. Up to know the only way I have found that is through drunken sex….followed by disgust…and more drinking’
Later suppor<ng dying mother of friend…less loneliness = less drinking
Neurological account
Normally, secure a^achment deac<vates mentalisa<on (‘love is blind’)
Psychotherapy offers secure a^achment…
while simultaneously insis<ng on mentalising the therapeu<c rela<onship…
Paradox continued
…pa<ent caught in an ac<va<on-‐deac<va<on bind
Enabling pa<ent both to be in<mate and see in<macy
Hence enhanced self-‐awareness and be^er chance of successful in<macy
C.f. rupture-‐repair
3 Cs
C1, Cross-‐bearing, brings into focus unconscious influences shaping the present moment.
C2, Connectedness, restores severed circuitry between the Self, Others and the Environment.
C3, Consciousness, encompassing all three, explores the in<macy of the therapeu<c rela<onship as a crucible for enhancing awareness: see, see, see.
Thanks….
for listening; if you want slides:
j.a.holmes@b,nternet.com