Content area
"Attachment and Adult Psychotherapy" by P. Sable is reviewed.
ATTACHMENT AND ADULT PSYCHOTHERAPY. P. Sable. Northvale, NJ: Jason Aronson, Inc., 2000.
Attachment theory is not just about infant-mother bonding anymore. This is clearly explicated in Pat Sable's new book, Attachment and Adult Psychotherapy. Clinicians have often expressed their uncertainty about how to use attachment theory concepts in adult psychotherapy. Sable's book is a much-needed reference. It is the first comprehensive catalogue of both the application of attachment theory and of the research it has generated in practice with adults. Sable personally collaborated with John Bowlby on the integration of attachment theory and clinical practice. She has been a pioneer in this area.
Sable organizes her book so that even newcomers to attachment theory will readily gain an understanding of salient concepts. She describes the history and development of the theory of childhood attachment and its validation through the research of Main (1984, 1985), Ainsworth (1978), Bretherton (1990) and others. She proceeds to explicate adult attachment with an emphasis on the development of cognitive-affective structures, patterns of attachment in adulthood, and the qualities of attachment in adult life. She describes the adult attachment research that has furthered our knowledge of adult attachment styles, intimate relationships, loneliness, grief, anxiety, and trauma. Then she turns her attention to defining psychopathology from an attachment theory perspective. Finally, she addresses the issues of how to integrate these concepts and the research on attachment in psychotherapy with adults. Sable manages this daunting task exceptionally well, particularly through the uses of her well-placed clinical examples.
Sable explains that when an attachment perspective is used to inform clinical work, there is a change in emphasis, a paradigm shift from drive theory, object relations theory, and self-psychology. Attachment theory helps us to organize and order the constellation of personality structures, symptoms, defenses, and psychopathology from a different perspective. It provides a framework for understanding personality development and its consequences that is based on actual and observable experiences. Of particular importance is the fact that it allows these concepts to be tested empirically. Attachment behaviors in children are observable and in adults can be revealed through observation of behavior in close relationships and questions that bring to light perceptions of self and others. Attachment theory provides a unified framework integrating psychodynamic thinking, cognitive science, and neurobiology. The change in emphasis or paradigm shift can be observed in this integration.
The attachment theory perspective that Sable describes begins with an infant's instinctual need to seek proximity with significant others and to form affectional bonds. The caregiver's ability to be sensitive and responsive to the infant's signals provides the basis for the development of a secure or insecure attachment and is an important ingredient in mental health. How the caregiver contains the child's affect is a factor in how affect will be regulated by the adult. The patterns of attachment developed over the course of the first year of life tend to persist. From earliest childhood, knowledge of self and other is contingent on what is experienced within the context of significant relationships. By the time children reach adulthood, their attachment patterns are stable and they will exhibit attachment behaviors that are characteristic in eliciting situations such as close personal relationships. In adulthood, attachment behaviors become mental representations or working models of self and others that are usually unconscious and mostly stable. Thus the theory is both spatial and relational in that it deals with proximity to the caregiver and affectional bonds with the caregiver. It is also concerned with how affect is regulated in the attachment relationship and the consequences of affect regulation for the adult.
Sable uses this understanding of attachment to elucidate the framework for the way in which the theory can be used in the practice of psychotherapy. First, the psychotherapy experience provides a secure base from which to explore the painful thoughts and feelings that bring people to the therapist's office. Thus the requirements for a secure therapeutic attachment are similar to those provided by the caregiver. The therapist should concentrate on being responsive to the needs and feelings of the client, available during sessions and between sessions and reliable in responses and reactions. The power of attachment is the organizing feature of the psychotherapeutic relationship. Beginning the process of establishing a secure attachment would be the first order of business. Establishing a secure base is the first goal.
Secondly, attachment theory helps us to construct a coherent narrative for the thoughts and feelings of individuals who are experiencing a variety of symptoms that do not make sense to them. As Sable suggests and research confirms (Main & Goldwyn, 1984) providing a framework for understanding disparate feelings gives psychological meaning to real experiences. It helps to desensitize feelings and encourages self-reflection. It allows for explanations without blaming the client. A coherent narrative is a significant organizing aspect of psychotherapy, which Sable sees as particularly helpful in the treatment of trauma and borderline personality disorder. It can explain the reactions of individuals in emotionally abusive relationships and also can clarify pathological grief reactions.
Thirdly, Sable explains that when transference is viewed from an attachment perspective, it becomes elaborated in a new way. Working models of self and other are interactive and are reciprocal parts of attachment history. So how clients react to the person of the therapist and her interventions becomes understood as partly due to those early childhood interactions and their internalization as working models. These working models impact clients' perceptions of themselves and others in the world. Helping clients see these perceptions and where they come from can feel normalizing. The therapist and the therapeutic work can become a part of a revised working model of self and other that is more reality based and more positive.
Finally, attachment theory provides clear and congruous explanations of three important aspects of psychological dysfunction: cognitive distortions, affect dysregulation, and defensive exclusion. From an attachment perspective, cognitive distortions develop as a result of a caregivers inability to respond accurately and lovingly to a child's unique qualities. Since working models of self and other are constructed from real interactions with attachment figures, it is important that a caregiver accurately reflects the child, so that that child can go on to perceive themselves accurately. Otherwise, they develop distortions in their working models of self and other. Helping clients who have these distortions becomes a process of more accurately reflecting their true nature in the relationship with the therapist. The therapist with an attachment perspective helps clients to see how these distortions developed.
The regulation of affect is an important focus of treatment that is well addressed through attachment theory. Children need a container for their intense emotions. Caregivers provide the function of helping children regulate the intensity of their feelings. They tend to internalize the way in which attachment figures provide this function; if caregivers do not do so adequately or are unable to contain their own emotions, children internalize inadequate regulatory mechanisms. Also, if caregivers are too restrictive in their regulation of affect, the child may develop an overly controlled regulation. Sable emphasizes the need for therapists to be cognizant of their role in assisting clients in affect regulation, in being the container for over or under regulated affect.
Defensive exclusion is another one of those concepts well known in the psychological literature but understood in a different way when seen in the context of attachment. Sable provides numerous examples of how defensive exclusion affected her client's functioning, particularly those with abusive or traumatic backgrounds. Bowlby (1982b) understood defensive exclusion as a response to the overwhelming anxiety that occurs when it is difficult or impossible to reconcile conflicting feelings about a person or traumatizing event. Since it is very confusing for a child to balance the love for parents with their disappointment for their failures of care or empathy, the child may exclude threatening events and feelings. These defensive exclusions are the result of real relationship experiences, not fantasies. Sable reports that the memories often come back gradually as the therapeutic relationship becomes more secure and provides a safe base to explore these frightening and unacceptable feelings and thoughts.
Thus, attachment theory truly provides a paradigm shift. It reorganizes our concepts of the therapeutic relationship by emphasizing the importance of providing a secure base for clients. It helps to explain personality development and psychological dysfunction from a new perspective, improving the way the concepts are understood and used in treatment. It insists on seeing personality development and its manifestations as the result of real experiences, thus making it easier for clients to understand and accept. It further elaborates our understanding of psychopathology. The theory itself is also being constantly tested and validated by psychological and neurobiological research, proving its validity and utility.
Sable shows us repeatedly how important it is for the therapist to provide the necessary ingredients for a secure therapeutic attachment; responsiveness, emotional availability, and reliability. These conditions create a secure base from which clients can begin to explore their concerns. Sable, a fine clinician, uses her in depth understanding of attachment to inform her clinical work, by helping her clients develop coherent narratives, more effective coping skills and more secure attachment styles. With this book, she has generously taken us into her consulting room, to demonstrate to us the practice of psychotherapy from an attachment theory perspective. As clinicians and seekers of truth, we are all enriched by her willingness to share her extensive knowledge and experience.
REFERENCES
Ainsworth, M.D.S., Blehar, M., Waters, E., Wall, S. (1978). Patterns of attachment:A psychological study of the strange situation. New Jersey: Lawrence Erlbaum Associates.
Bowlby, J. (1982a). Attachment and loss: Volume 1. New York: Basic Books.
Bowlby, J. (1982b). Separation: Anxiety and anger. New York: Basic Books.
Bowlby, J. (1982c). Loss, sadness, and depression. New York: Basic Books.
Bretherton, I. Ridgeway, D., and Cassidy, J. (1990). Assessing internal models in the attachment relationship: An attachment story completion task for 3-year-olds. In Attachment during the preschool years. ed. MT. Greenberg, D. Cicchetti, and E. Cummings. Pp. 272-308. Chicago: University of Chicago Press.
Hazan, C., and Shaver, P. (1987). Romantic love conceptualizes as an attachment process. Journal of personality and social psychology. Vol. 52, No. 3, pp. 511-524.
Main, M. And Goldwyn, R. (1984). Predicting rejection of her infant from mother's representation of her own experience: Implications for the abused-abusing intergenerational cycle. International Journal of Child Abuse and Neglect. Vol. 8, pp. 203-217.
Main, M. (1995). Recent studies in attachment: overview, and selected implications for clinical work. In Attachment theory: social, developmental, and clinical perspectives. Ed. S. Goldberg, R. Muir, and J. Kerr, pp. 407-474. Hillsdale, NJ: Analytic Press.
Copyright Human Sciences Press, Inc. Spring 2002