loss as a metaphor for attachment

LOSS AS A METAPHOR FOR ATTACHMENT

George E. Vaillant

Contrary to folklore and psychiatric myth, separation from and loss of those we love do not cause psychopathology. Rather, failure to internalize those whom we have loved-or never having loved at all-causes psychopathology. During the course of psychotherapy or analysis, patients often "discover" forgotten loves. When this happens, the process of internalization moves forward. This observation derives from the fact that the psychodynamic work of mourning is to remember more than it is to say goodbye.

But if loss does not kill and if loving allows us to survive, why is there so extensive a psychoanalytic literature on loss and such a scanty one on internalization? I believe that the discrepancy derives from confusion between metaphor and myth. We have no language for internalization and a very limited one for attachment. The discussion of grief, loss, and separation provides patients and therapists alike a metaphor for discussing attachment and the people who live within us.

Unfortunately, psychoanalysis has a bad habit of turning metaphor into myth. When this happens error results. For example, one of the great contributions of Erik Erikson (1) was to help us to take the stages of orality and anality less literally; he has taught us that the terms serve as metaphors for the more critical developmental issues of trust and autonomy. Metaphor, like poetry, allows us to use mere words to encompass affect-laden relationships. Metaphor, like song, allows us to appreciate that those people whom we invest with affect may be taken inside. Myths, on the other hand, lead to sterile orthodoxy and unnecessary schisms in psychoanalytic insti- tutes. The song "I've Got You Under My Skin" has more to teach a psycho- analyst than a fundamentalist exegesis of Jonah and the whale. Students of object relations theory too often begin to take their metaphors literally;

An abbreviated version of this paper was presented at the symposium, Separation and Loss: Clinical Issues, at The Association for the Advancement of Psychoanalysis, New York, March 1984.

George E. Vaillant, M.D., Raymond Sobel Professor of Psychiatry, Dartmouth Medical School, and Faculty Member, Boston Psychoanalytic Institute.

The American Journal of Psychoanalysis © 1985 Association for the Advancement of Psychoanalysis

Vol. 45, No. 1, 1985

59

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and thus, believers in the sacred importance of "good" and "bad breasts" forget that Melanie Klein never breast fed her children. Myths retard science.

To take what psychiatrists say about separation and loss too literally, to ignore that grief can be metaphor for attachment, is to risk therapeutic rigidity. Consider, for example, the not uncommon situation of a psychiatric resident helping a patient to grieve the previous resident who had helped the patient to grieve the previous resident and so on back through several training generations. By turning the metaphor of the value of grief work into literal myth no one ever asks, what does the patient really need? Why did she/he first seek therapy? Is sensitivity to loss of the resident the issue or only a marker of the real pathology?

Consider, de Saint-Exupery's aviator in The Little Prince (2). It was quite clear that, in losing the Little Prince forever, the aviator (through the Little Prince's mediation) has become enriched forever. Wheat fields will never be the same again; always they will glow with the gold of the Little Prince's hair. No one that we have ever loved is totally lost, and it is very hard to lose someone whom we have never loved. Admittedly, it is often painful to the point of mental illness to lose someone whom we have loved a little and hated a lot.

To resolve this paradox, the question must be asked: what allows some people to be enriched by the peop!e they have loved and lost and others to grieve them forever? I believe that the answer is differences in successful internalization. This is why internalization is such an important concept. Internalization offers us a shorthand for discussing the psychic metabolic process which assimilates split objects and leads to object constancy.

Consider a rather different illustration of myth, metaphor, and object relations. In the early 1950s, separated from Melanie Klein by six thousand miles, Otto Kernberg in Chile accepted her myth of development, a model where separation and loss before the age of three exerted critical effects upon adult development. His loyalty to this myth-and his great clinical acumen-has made Kernberg a hero to a generation of American psychiatric residents. During the same time period, Klein's model served as a poignant metaphor for Melitta Schmideberg, a young woman who re- nounced both her mother, Melanie Klein, and her mother's ideas and emi- grated three thousand miles away. Schmideberg resettled in England only after her mother's death. The relevance of this contrapuntal example is that both Schmideberg and Kernberg have made seminal contributions to our understanding of object relations and "the borderline" (i.e., character pathology in young adults) (4, 5). Kernberg writes as if Klein's model is literally true; Schmideberg behaved as if her mother's model was metaphor for the vicissitudes of young adult development.

Both examples illustrate that Melanie Klein's writing (3) serves as a very

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evocative and suitable fairy tale for what goes on in the efforts of adolescent and young adults to separate and individuate. If read as poetry, Klein's work captures the dyadic vicissitudes of psychotherapy with severely per- sonality disordered patients. For both patient and therapist the struggle over separateness and merging becomes paramount. By unwittingly pro- jecting the struggle onto the 1-year-old patient, Klein allows psychiatrists to absorb truths that might otherwise repel them. But her daughter's behavior reminds us that separation/individuation from our parents is a lifelong process, the point being that separation/individuation is not inhibited by loss but enabled by loving. It is loving that saves us, not loss that destroys us; just as it is the people who stay in our lives that drive us mad, not the ones who leave.

With this introduction let me describe two sets of empirical data that support my contention that loss is metaphor for attachment. As a resident, I had been greatly influenced by Elvin Semrad as a teacher and John Nemiah's book, Foundations of Psychopathology (6). I believed that early object loss per se and incomplete mourning made critical contributions to adult development and psychopathology. Indeed, the psychodynamic literature of the late 1950s suggested that early object loss might be the etiology of schizophrenia.

Five years later, in undertaking the refollow-up of the subjects of Har- vard's (Grant) Study of Adult Development, a study which had followed 268 men from adolescence until middle life, I focused on parental loss, on adult depression, and on oral dependence (7). I contrasted age of parental loss among thirty middle-aged men with the best psychological outcomes and the most mature object relations with age of parental loss for the thirty worst outcomes. I tried to enhance this effect by also assessing age of parental loss in their parents. I paid special attention to the adult outcome traits of self-doubt, pessimism, passivity, and dependency-in short, to chronic depression. To my surprise, the best and worst outcome groups did not differ in the extent of childhood parental loss, in their own lives or in that of their parents. Indeed, it became clear that as one looked at the men's lives prospectively, a very different view emerged from the one that we obtain in the consulting room where we have to reconstruct lives by looking backwards.

As any historian knows, effort to recall the past produces legend and myth. If historical myths have symbolic value, we believe them, but our belief does not make them true. Once adequate geological data was ob- tained, it was shown that much of the Old Testament makes better metaphor than history. Thus, as I followed these men's lives forward, I found that the traits of orality and dependency made it difficult to grieve, rather than that separation and loss created the traits of orality and dependence.

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I also found that the etiology of orality and dependence was having lived with inconsistent, immature, and incompatible parents; not having lost good parents.

A second variable related to chronic depression in adults was incapacity to internalize-in Kernberg's terms (4), incapacity to "metabolize"- important childhood figures. For example, there were two brothers in the Grant Study of Adult Development, one of whom had exhibited tragic flaws and one who did not. In their oedipal years, they lost their father to the opposite coast and to alcoholism. A strong, overbearing mother remained behind. One son became a champion wrestler, openly fought with his mother, and found that by crossing both the country and the barriers of his father's alcoholism, he was able to make close friends with him. Indeed, for the rest of his life this brother continued to experience repeated object loss and to heal those losses with an extraordinary capacity for intimate friendship. The other brother foundered. He was overwhelmed by his mother; he never re- formed a relationship with his father; and later, he sought geographic separation from his remaining family.

Let me offer a more dramatic example of a man who, alas, was not in the Study of Adult Development. By death he lost his mother when he was 2, his father when 9, his surrogate mother (his grandmother) when 10, and when he was 13 years old, the two aunts who had stepped in as parental surrogates also died. Not surprisingly, for the next ten years he became a delinquent, for whom splitting was a dominant defense. He became a narcissistic high school dropout with a vivid fantasy life and might well have qualified for the label, borderline. Five decades later, we find him at the age of 77 years (not at 2 or 3) writing on a loose piece of paper, "Felt dull and sad all day . . . . I wanted as when I was a child to nestle against some tender and compassionate being, and weep with love and be consoled. . . become a tiny boy, close to my mother the way I imagine her. Yes, yes, my Mama (whom I was never able to call that because I didn't know how to talk when she died) . . . . Mama hold me, baby me!" (8, p. 14).

Parenthetically, the writer acknowledges the problem that we do not "know how to talk," except through song and poetry, about attachment bonds. The language of psychoanalytic metapsychology can never encompass the meaning of "Mama." At the time Count Leo Tolstoy scribbled his Iongings, he was not a borderline struggling to fill a bottomless void; he was the best known man in the world, a wise adult who would serve as inspiration to both Gandhi and Martin Luther King, Jr. He had never read Harlow, Winnicott, Bowlby, or Freud. Rather, he was an adult about whom myths of invulnerable children are spun. Vulnerable Tolstoy was. But Tolstoy, like the eldest brother in my first example, had an extraordinary capacity to internalize, to take people inside and to grow as a result.


Unfortunately, we do not know what allows some people to have that capacity to internalize, but that must become a major area of psychoanalytic research. Certainly, one of the outstanding assets of Tolstoy's life was that he was blessed with a rich (pun intended) extended family whose members allowed him to practice relationship after relationship until he finally learned both to depend upon the love and to grieve the death of his family members. A danger of the modern, small, nuclear family may be that it limits object choice.

Initially much influenced by the work of John Bowlby, Michael Rutter has tested empirically the importance of separation and loss upon child development. Again, rather than use the retrospective methods on which clinicians must depend to study attachment and separation, he (:hose pro- spective designs. When he examined the effect of separation and loss upon children who had been followed forward in time, he reached very different conclusions from those reached by psychoanalysts.

Let me summarize just five of the findings from Rutter's classic review, Maternal Deprivation Reassessed (9). He noted that it was a child's poor interpersonal relationships and conflicted parental relationships that pre- dicted emotional disturbances during medical hospitalization, not the strength of attachment. Indeed, short term distress was less if the child had had a good relationship with his or her mother. Second, Rutter noted that it was exposure to a conflict-ridden but enduring marriage, and not to parental death, that scarred a child's future development.

Third, he noted that, by maintaining old routines and by remembering the lost parent, attachment bonds to the original parent can be kept alive in temporary foster homes. Again, this finding addresses the critical issue of both de Saint-Exupery's aviator and of Tolstoy's life. Grief work is remembering, not forgetting; it is a process of internalizing, not extruding. Attach- ment, if properly treated, provides us strength forever.

Fourth, Rutter makes a distinction between privation and deprivation. Privation, never having loved or been loved, leads to emotional disability. Deprivation, losing one we have loved, leads to emotional distress. The difference between disability and distress is the difference between behavior and talk. To lose someone whom we have loved and been loved by produces grief, not psychopathology; tears, not patienthood..As Tolstoy wrote, "Only people who are capable of loving strongly can also suffer great sorrow; but this same necessity of loving serves to counteract their grief and heals them . . . . Grief never kills" (10, p. 109).

The fifth point made by Rutter's review is that failure to form attachment bonds has a far worse prognosis than forming bonds and then having them broken. To have never loved, to never have formed an enduring attachment, affects what people do, rather than just what they say. Such privation

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leads to many of the pathological grief reactions with which psychiatrists are familiar.

An illustration of Rutter's five points was provided by a member of the Study of Adult Development. This man had grown up with very eccentric, paranoid, if socially proper, parents. At age 46 he could write without hyperbole, "1 neither liked nor respected my parents." While in college, he asked his parents for permission to join the Study. They tried to forbid it, for they believed that by participating in the Study, he would receive experimental drugs.

Since he had experienced his parents as both unloving and overprotec- tive, he had insisted on going to boarding school. The consequences of inadequate internalization led to inability to deal with his self-willed separation. In college, this was illustrated when he described the first Ror- schach card as " . . . a butterfly that has been killed because a thoughtless boy opened its cocoon too early and set it free. The butterfly needed to struggle to escape, and premature release had been fatal." Consistent with this projective test was the observation by the Study staff that he was severely hypochondriacal and was repeatedly medically hospitalized without physical illness. On graduating from medical school, he could not tol- erate the autonomy of internship. Instead, he made a suicide attempt and received brief psychiatric hospitalization; he spent the next year in the safety of the pathology, laboratory and the next 10 years working as a staff doctor in institutions. How shall we understand this lack of autonomy? Was it his failure of separation/individuation prior to age 3 and his inability to assimilate parental loss, or was it his adolescent failure to internalize ambiv- alently regarded parents and thus to fail at object constancy? The answer is not a simple one, and both questions must be seriously considered.

At age 35, he was still single, working as an institutional physician and resenting his patients. While skiing, he broke his leg. He developed severe osteomyelitis and was medically hospitalized for a year. In my interview with him at age 47, he surprised me because he did not view this serious interruption of his career as traumatic. He explained, "1 was glad to be sick. Someone with a capital'S' cared about me. It made me feel that I was nutty for a while, but in the Catholic church it is known as Grace. Nothing has been as tough since that year in the sack." After his leg had healed and he was discharged, he sought psychoanalysis. Within five years he had become an independent physician, had organized a clinic which he directed, had married, and had had children.

What is the explanation? An intuitive child psychiatrist blind to his outcome had been asked to rate his childhood. She agreed that it was one of the bleakest in the Study, but she observed that up to age 5 he had had a very good relationship with his nurse. She wondered if someday that


would not provide a source of strength. Was the healing function of "that year in the sack" and his analysis to put him again in touch with a source of internalized strength? I think so.

What I am suggesting is that psychoanalysis may cure us as much by enabling us to recover the people that we have loved and forgotten as it does by helping us to mourn the people that we have lost. Some patients internalize people better than they know but have conscious access only to the hated facets. In therapy, mourning helps them recover the beloved but split off fragments. An illustration of this is that a major task of Tolstoy's adult life was assimilating the split representations of his mother and finally integrating them in his fictional account of Anna Karenina.

Let me describe another man from the Study of Adult Development. Like the previous example, this man was retarded in adult psychosocial development. In his college psychiatric interviews, the subject perceived his mother as the dominant force in his life. She had selected his high school friends and had chosen his college major. She had asthma and hay fever; he had asthma and hay fever. His solution to the fact that his parents were of different religions was to choose his mother's church. As he explained to the research psychiatrist, his father was distant, passive, and suffered from dyspepsia. The Grant Study staff believed him.

At age 25, the subject had not yet seriously dated. Having received a fellowship to study romance languages in Paris, he went to his dentist and had bands put on his teeth. As he told me years later, "There I was making myself look 12 years old . . . . I was adding to my immaturity." However romantic Paris might be, he could still pass for a seventh grader. In his late thirties, he was psychoanalyzed. When I interviewed this man at 47, he now was chairman of his university department, married, and a father. By Erikson's standards, he was clearly generative, at peace with himself, a n d - metaphorical ly-no longer wore bands on his teeth.

At our interview when he was 47, I asked about his parents. He described his mother as an ineffective, psychoneurotic woman who had played a minor role in his life. He now remembered his father as a very important person, a man with a wonderful sense of humor, and whose religion he had recently adopted. Although for years untroubled by his motheds asthma and hay fever, his father's dyspepsia was now his dyspepsia. Perhaps it was not a coincidence that his father had died a year before. Internalization of important people is facilitated by loss as often as loss impairs internalization. I asked him what had he learned from his analysis. He replied that he had learned how to be " . . . more how I was at 4 and less how I was at 7."

What about the men in the Study who failed to internalize? They were men who continued to live with inconsistent parents, not those who, like Tolstoy, had suffered repeated losses. Both parents of one such man had

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experienced nervous breakdowns during his adolescence. At age 47, he was still unable to leave his family or form new love relationships. He worked regularly, however, and a two hour interview provided no evi- dence that he deserved a DSM III diagnosis. But there was no one in his life beyond his nuclear family. As he put it, 'qaking care of cats is a big affair."

I asked another subject with a similar background if there were anyone in his whole life who had "touched his heart." Although he was 60 years old, he replied, "1 think no one. That is my character. It is a terrible thing." As a partial explanation, he revealed that during his mother's bouts of manic depression, "When young I learned to steel myself." On the one hand, at 60 this man had given up all hope, loved nobody, and brooded about his osteoarthritis. He saw himself as a failure and there was no one except his mother inside. On the other hand, he was not schizoid, nor had he ever experienced his mother's bipolar illness. He was a man who hact won the literary respect of his nation and was able to ask me extremely wise and mature questions about my longitudinal study. He neither felt sorry for himself nor had he ever sought psychiatric care. His only failing was to be without attachment. He was unable to remember loving any- body. True, if he wished, we could label him a narcissistic character, but narcissism is often only a multisyllabic synonym for "pain."

To conclude, the developmental process to which psychoanalysis should pay the greatest attention is internalization throughout the life span. Separation and loss in early childhood may be less critical to later life than we believe. But by attending to our patients' experiences of separation and loss, we allow them a metaphor with which they can describe the vicissitudes of their attachments. In a different but related vein, I believe that the separation/individuation process of infancy, as depicted by Melanie Klein and Margaret Mahler, often attracts our attention because it provides a metaphor that describes the struggle for identity that characterizes young adulthood. No wonder our residents are fascinated by the "infantile" struggles of borderlines.

We need more data about internalization and fewer myths. In discussing the resolution of ambivalent feelings towards parents, Searles (11) reminded us of a children's book about a wise grandfather rabbit who, when he died, turned into a beautiful sunset. That is a good metaphor with which to close this paper.

REFERENCES

1. Erikson, E. Childhood and Society. New York: Norton, 1950. 2. de Saint-Exupery, A. The Little Prince. New York: Harcourt, Brace and World,

1943.


3. Klein, M. Envy and Gratitude and Other Works, 1946-1963. London: Tavistock Publications, 1957.

4. Kernberg, O.F. Object Relations Theory and Clinical Psychoanalysis. New York: Jason Aronson, 1976.

5. Schmideberg, M. The borderline patient. In S. Arieti (Ed.), American Hand- book of Psychiatry. New York: Basic Books, 1959.

6. Nemiah, J. Foundations of Psychopathology. New York: Oxford University Press, 1961.

7. Vaillant, G. E. Adaptation to Life. Boston: Little, Brown, 1977. 8. Troyat, H. Tolstoy. New York: Doubleday, 1967. 9. Rutter, M. Maternal Deprivation Reassessed. Harmondsworth, England: Penguin

Books, 1981. 10. Tolstoy, L. Childhood. New York: Thomas Y. Crowell, 1899. 11. Searles, H.F. Separation and loss in psychoanalytic therapy with borderline

patients: further remarks. Am. J. Psychoanal., 45: 1985, this issue.

Reprint requests to: George E. Vaillant, M.D., Dartmouth Medical School, Hanover, NH 03756.

loss as a metaphor for attachment

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