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Psychotherapy with Attachment and the Brain in Mind

Daniel J. Sonkin, Ph.D.
Licensed Marriage and Family Therapist
Sausalito, CA.

Sonkin, Daniel, J. (2007).  Psychotherapy with attachment and the brain in mind.  The Therapist. Vol 19, Issue 1 (January/February), pp 64-70.

 “Happy families are all alike; every unhappy family is unhappy in its own way.”

This quote by Leo Tolstoy in the opening line of his book, Anna Karenina, aptly characterizes an important difference between families that imbue secure attachment in their children and those that don’t.  In families where both parents experience secure states of mind, they demonstrate a common sensitivity with each other and their children that provide the optimal environment for healthy social and emotional development. Many secure parents can’t always describe what it is that they do, they just do it, and the outcome is usually very positive and consistent for the children.  Fortunately, over fifty years of research on attachment theory has revealed the specific competencies that securely attached parents utilize in their interactions with their children.  Terms like sensitivity, cooperation, and attunement in the early phases of attachment research have evolved into terms such as coherence, emotion regulation and neural integration in more recent years.  Although these terms all have somewhat different technical definitions, they all suggest that that road to raising secure children tends to involve a consistent set of behavioral skill sets that are neurologically based.

On the other hand, in families where parents are unable to provide optimal sensitivity and attunement, depending on the parent’s particular difficulty, the child is forced to adapt in such a way that may result in their developing one of a number of maladaptive strategies or competency deficits.  These deficits or problematic strategies are most likely to manifest in the social and emotional realms.  In other words, not all children in unhappy families turn out to be unhappy in the same way – it in part depends on the way each parent is unhappy.  To make matters more complicated, because the brain is an integrated organ, maladaptive strategies in one domain are likely to affect functioning in another.  For example, it has been demonstrated that problems in emotion regulation may have an effect in cognitive development.  Not that secure attachment is an automatic entry into Stanford, but that attachment security may contribute to lower rates of anxiety, increased competence and more positive interpersonal relationships which is likely to result in less compromised learning.  In contrast, some children with insecure attachment may find learning more difficult for a variety of reasons including, but not limited to, increased anxiety and poorer emotional regulation skills.

One of most exciting developments in psychology is our dramatic increase in understanding the structure and function of the brain and how it brings about consciousness and psychological processes.  These newer understandings of the brain and the mind have been invaluable to the field of psychotherapy.  Studies in neurobiology have not only shown that the brain is continually evolving over our lifetime, but that it is receptive to environmental stimuli and therefore can change in response to stimuli.  This has led to the notion that psychotherapy changes the brain, not just behavior.  Some people have suggested that psychotherapy may be thought of as a process of non-invasive neurosurgery.  Studies in the field of cognition and affect have expanded our understanding of emotion – an area that is the focus of many forms of psychotherapy.  Older notions of the separation of thought and emotion have been replaced by contemporary theories suggesting that emotion and cognition are inextricably linked – you can’t have one without the other.  Likewise, recent findings in the field of memory have helped to explain many phenomena observed in the various psychological specialties, such as trauma, intimate relationships, parenting and therapeutic transference.

This article with present a brief discussion of recent findings in the areas of attachment and neurobiology and suggest ways in which therapists can incorporate this knowledge into their clinical interventions.  This is a very exciting time to be a psychotherapist.  There is a wealth of research in these areas and as a result, the data can be overwhelming and its application can be open to interpretation.  Although our knowledge of the brain and attachment has increased exponentially in the past sixteen years, there is much more that we don’t know, than we know.  Therefore, it is suggested that the reader keep this fact in mind, as you read about the research and my suggested application to the practice of psychotherapy.

Attachment Theory

In a landmark series of studies entitled Attachment and Loss, John Bowlby outlined a remarkable theory that posited that early attachment had sociobiological significance and constituted a powerful human survival motive. Primary attachment (usually to the mother) is governed by three important principles: first, alarm of any kind, stemming from any source either external or internal, activates an attachment behavioral system in an infant that directs and motivates the infant to seek out soothing physical contact with the attachment figure.  Second, when activated, only physical attachment with the attachment figure will terminate the attachment behavioral system.  Third, when the attachment behavioral system has been activated for a long time without soothing, or is only intermittently soothed, the system can either become suppressed or hyper-activated. 

Bowlby reported observations he made of 15 –30 month old children separated for the first time from their mothers. He witnessed a three phase behavioral display: protest, despair, and detachment.  He concluded from these observations that the primary function of protest was to generate displays that would lead to the return of the absent caregiver.  Subsequent empirical studies by Mary Ainsworth and her colleagues showed that different attachment statuses existed for infants.  These attachment categories were labeled: secure, anxious-avoidant (referred to as dismissing attachment in adults), and anxious-ambivalent (referred to as preoccupied attachment in adults).  A fourth category emerged in their research that was eventually called disorganized (referred to as disorganized or unresolved attachment in adults). Based on an experience she had in studying parenting in Africa, Ainsworth developed a brilliant method of assessing attachment in the laboratory. 

The Strange Situation has become a widely utilized protocol for the assessment of infant/parent attachment.  It consists of a specific series of interactions, separations and reunions of the caretaker with their infant.  The procedure is recorded and analyzed by the researchers.  Specific patterns of behavior are observed with each attachment category.  Secure children are typically distressed at the absence of their caregiver but are quickly soothed upon reunion.  The anxious-ambivalent and disorganized types experience extreme anxiety during separation and seek proximity to their attachment figure upon reunion, but experience varying degrees of anxiety as they approach. The disorganized children are particularly ambivalent upon reunion with their attachment figure, both simultaneously approaching and avoiding contact.  Many of these infants display a collapse of attachment strategies resulting in what some authors have described as dissociated behaviors.  Bowlby described these children as “arching away angrily while simultaneously seeking proximity” when re-introduced to their mothers.  Interestingly, although the anxious-avoidant children seem content in the absence of their attachment figure and not particularly interested in seeking proximity and soothing upon reunion, when physiological measures are taken, these children are quite anxious during separation, but somehow learned to suppress their emotions.

The development of the Adult Attachment Interview, as well as other adult attachment measures, has allowed researchers to examine the relationship between the parent’s attachment status and the attachment status of their children.  It will come as no surprise that these two correlate very highly. It has been found that the attachment status of a prospective parent will predict the attachment status of their child to that parent with as high as 80 percent probability.  Longitudinal studies of attachment have demonstrated a high continuity between infant attachment and adult attachment patterns.  However, these longitudinal studies have also suggested that changes in attachment status can occur in either direction (secure to insecure, insecure to secure).  The term "earned secure" has been used to describe individuals who moved from an insecure status to a secure status.  However, for the majority of individuals, the manner in which they learned to regulate attachment distress early on in life will continue unless their circumstances change or other experiences intervene.  For many people, the coping mechanisms may become more sophisticated, but the net result (over-activating or under-activating in the case of insecure attachment, and modulation with secure attachment) will essentially continue.

What I find exciting about the attachment literature is that it gives therapists a new paradigm for understanding affect regulation strategies, interpersonal relationship dynamics and the therapeutic alliance – all of which are important areas of focus in many psychotherapeutic theories and modalities.  It is not as important to assess the attachment status of a patient (though I personally find it helpful) as it is to know that there are different strategies for regulating attachment distress (hyperactivating, deactivating, dissociation or collapse), and that a particular patient may utilize one or more of these strategies in regulating emotions associated with close relationships.  It is also important to realize that over time the therapist will also become an attachment figure. Bowlby described a series of stages as attachment develops: preattachment, attachment in the making, clear-cut attachment and goal corrected partnership. As the therapist becomes an attachment figure for the patient, the therapist can begin to observe and experience first-hand the quality of the patient’s attachment to him/her.

Another clinically relevant finding in the adult attachment field relates to the concept of secure base priming. Mario Mikulincer and Phil Shaver have been able to empirically test the notion that creating a secure base experience for individuals may temporarily alter an individual’s inner working models of others and therefore, change behaviors or emotional states. They hypothesized that having a secure base could change how a person appraises threatening situations into more manageable events without activating insecure attachment-like behaviors such as avoidance, fear, or preoccupation. They utilized a series of well-validated secure base priming techniques that have appeared to create in subjects a sense of security one would find in individuals who might otherwise be assessed as having a secure attachment style.  These techniques were quite creative, had therapeutic correlates and had powerful effects on subjects in the study. In all five of these studies, those subjects exposed to secure base priming acted in the experimental condition similar to securely attached individuals who did not receive priming, but were nevertheless exposed to similar conditions assessing intergroup bias.  The authors suggest that secure base priming enhances motivation to explore by opening cognitive structures and reducing negative reactions to out-group members or to persons who hold a different world view.  The observed effects of secure base priming may reflect cognitive openness and a reduction in dogmatism and authoritarianism.  Other similar studies have found that secure base priming also had a positive effect on cognitive and affective states.

The priming techniques utilized in these studies are important to note since they all have their psychotherapy correlates.  One group was primed using subliminal presentation of words that exemplify a secure schema (e.g., love, support) within a word relation task.  This is not unlike the therapist who gives verbal as well as non-verbal messages to a patient communicating support, caring, and empathy.  In another study, participants performed a guided imagination task in which they visualized an interpersonal episode containing the prototypical if-then sequence of the secure base schema.  The clinical corollary to this may be helping a patient imagine a situation with positive outcomes, such as one used by cognitive-behaviorists called rehearsals with a positive outcome. The third priming technique was a visualization task, in which participants visualized a real person who served as a secure base for them.  It is our hope that therapists can be that real person with whom they can have a secure base relationship.  It is not uncommon for patients to report visualizing or remembering a positive interaction with their therapist and how it served them outside of the consulting room.  From an attachment point of view, psychotherapy can be repeated positive interactions involving sensitivity, attunement, disruption and repair, that becomes encoded in the patient’s memory not unlike the priming that Shaver and colleagues have found to be powerful forces of short-term change.

The Neurobiology of Emotion

What therapist doesn’t work with emotion?  We all do, whether it is explicit in our orientation or not.  Our patients are emotional beings and as such, they are constantly (as we are) experiencing varying types and intensities of emotion.  In fact, this is one of most enlightening findings in the affective neurosciences – that throughout most of our day we are experiencing emotion.  We may not be having the concurrent feelings (i.e., awareness or mental representation of the emotion), but we are having the emotion just the same.  In fact, we are probably not aware of most of the emotions we are experiencing – and this is a good thing. Although emotions can provide us with important information about an event and help us make decisions in daily life, if not adequately regulated, they can also be distracting from other important tasks at any moment in time.  Similarly, if their importance is underestimated, we are missing important information that allows good decision-making and social problem solving. 

For psychodynamically oriented therapists in particular, knowing what we are feeling is critically important to knowing what our patients are experiencing at any moment in time.  Fine attunement to the ebbs and flows of emotion in our own physical being can teach us something about the inner world of our patients.  The more analytically trained therapists will recognize that I am speaking about projective identification.  It turns out that this analytic concept has a neurobiological correlate – the mirror neuron system.  The mirror-neuron system allows our mind to read the intention of others through non-verbal cues.  During the course of a session, we are constantly picking up the non-verbal emotional cues of our patients. Our mirror neuron system, located in the prefrontal cortex of our brain, simulates that state in ourselves.  It has been suggested that this system is the neurological basis of empathy.

The work of Antonio Damasio has been very applicable to the practice of psychotherapy. He suggests that the terms emotions and feelings refer to two very different processes.  Emotion can be thought of as the body’s response to an emotionally competent stimulus.  These stimuli are frequently handed down by evolution, but can also be learned.  An emotionally competent stimulus will cause a change in the physical state of the organism – therefore, emotion begins in the body (turns out the body-oriented therapists were quite right about this notion).  Emotional reactions are solutions to these events and may occur completely out of our awareness.  How many times have you come home upset after a particularly difficult day or session and not having the slightest that you were upset until someone asked, “What are you upset about?”  The emotion occurred and a solution was employed without any awareness.  It not until the prefrontal cortex of the brain registers the change in the body and represents it either verbally or non-verbally, that a feeling occurs.  Feelings are mental representations of emotional reactions in the organism.  So, in psychotherapy, a great deal of our work is helping patients not only recognize that something is happening to them emotionally, but also developing the feeling language to express it and the reflective ability to understand it.  As you may have already figured out, dismissing attachment in adults is a short-circuiting of this process – there is either unawareness of the emotion, the lack of words to represent it as a feeling, or both.  Preoccupied attachment is the over-stimulation of emotion that overwhelms the system, such that representation can become confusing or besieged.

Another interesting finding is how emotion is linked with thought.  The notion that thoughts and emotions are separate phenomenon is probably inaccurate.   Damasio has suggested that it is unlikely that one can have a thought without a corresponding emotion.  In fact, we use emotions to make decisions all the time.  We may not be aware of it, but like most emotions, they are operating below the surface to help guide us in our choices.  So, when I am engaged in a stimulating conversation with my patient, there is a good chance that there is an emotional subtext that is present.  It may not be always important to make that explicit, but if your patient has developed their intellect to compensate for a weakness in their emotional competence, then it is critical that therapists become aware of their state of mind.

Neurobiology of Memory

Memory is the way our brain learns and how it anticipates the future.  If psychotherapy is about learning, then memory is involved.  Additionally, every therapist begins his or her work with a patient by obtaining a social history, which is an assessment by memory.  One of the most important findings in the field of memory research is the idea that there are two types of memory – explicit and implicit.  Both are important to the practice of psychotherapy, but understanding the process of implicit memory helps us help our patient better understand why they may react the way they do.

Explicit memory, which is mediated via the hippocampus, is a type of memory that we are most familiar.  It involves asking the patient to recall events, data or facts (also referred to as semantic memory) about their lives.  It can also include autobiographical descriptions (also referred to as episodic memory) that involve recalling earlier events.  You can know that it is episodic memory when there is a sense of the “self” included in the narrative.  Implicit memory, which is mediated via brain circuits independent of the hippocampus, is a form of memory that may have any one or a number of components including: cognitions, emotions, behaviors, perceptions, mental models, bodily sensations, or skill sets.  Two important differences between explicit and implicit memory are that with implicit memory: 1) you don’t need focused attention for it to occur, and 2) when it’s recalled there isn’t a sense of remembering.  During the first two years of life, before the hippocampus is fully developed, most learning is occurring through implicit memory processes. Many attachment-related memories are implicit.  Working models of self and others involve implicit memory. When we are experiencing implicit working models of attachment, we are not aware that we are experiencing a form of memory - there is just a sense of knowing or simply responding. These implicit working models are often activated by current emotionally competent stimuli.  The example below will illustrate how a behavior on my behalf will trigger an implicit memory in my patient, but will not be conscious.  Instead, he will just respond in the way that is familiar to him.  The goal of psychotherapy is to make implicit processes explicit, so that the patient can then have a choice in responding.

Integrating Attachment and the Neurobiological Findings

A patient that I have been working with for approximately one year, who may be assessed as preoccupied from an attachment perspective, came to his session recently slouched down on the couch and visibly unhappy. When asked about his emotional state in this particular session, he was unaware of experiencing any feelings.

He grew up an only child.  He describes both parents as “functional alcoholics.”  His father was often absent from the family, but when he was there, he could be extremely angry and abusive toward my client.  His father died almost twenty years ago.  His mother was extremely anxious, who made it quite difficult for him to have emotional reactions or needs without her becoming quite disregulated herself.  He learned in childhood that if he could help her calm down, he would feel more connected and less threatened. When he needed caretaking, her need for caretaking became paramount. In essence, there was a role-reversal between my patient and his mother, which still continues to this day.

He sought therapy due to having a long history of sexual infidelity in his marriage.  He has made some recent progress in making a firm decision not to act out.  However, he reports that when he visited his family, he had made contact with an old girlfriend with whom he is still very attracted.  To complicate matters, she disclosed to him that she was planning a business trip to this area, which was coming up in a few days after this session.  They made tentative plans to get together. 

For some reason unbeknownst to me at the time, I became mildly confrontational about his tentative plans to, what I viewed as, act-out with this woman. I noticed that he shut down immediately.  I thought how his behavior seemed very young - almost like a little boy who was pouting and refusing to talk.  I noticed in myself a feeling of slowly mounting anxiety.  I wondered if this is my anxiety, or his, or both.  I was probably experiencing his anxiety about acting out and breaking his commitment.  But I was also worried about our taking a step backward in the therapy.  As we sat there silently, I reflected on my anxiety and what would be the best way to proceed.  I wondered if he experienced my confrontation as anxiety – just like his mother.  He came into the session obviously needing caretaking (even though he wasn’t conscious of it) and I became anxious just as his mother would when he needed caretaking from her.  I decided to change tact and express interest in this woman, not unlike a parent might ask about a new friend their child met at school that day. He slowly opened up and started to talk about this woman, and from there we talked about his experiences at home and how those experiences may have led him to seeking soothing from this woman.  At the end of the session, we briefly touched on what happened between us, but I realized that didn’t need to be explicit.  What was more important was that I managed the anxiety that I experienced (whether his, mine or ours) in order for him to get the caretaking he needed.

There are many different ways of analyzing this brief interaction, but for the sake of this article, let me relate it explicitly to the research presented.  With preoccupied attachment, this individual hyper-activates the attachment behavioral system, and presents with extreme anxiety.  What he needs is help containing the flow of emotion and processing it into its component parts (e.g., anger, sadness, guilt, etc.).  When this patient went home to visit his family, it probably triggered many emotions, but because he still lacked the ability to process them consciously, they are experienced as anxiety.  To protect and soothe himself from the anxiety, he sought soothing from another person, which in this case, was sexual interest in this woman.  The anxious-ambivalent (preoccupied) infants used proximity maintenance (clinging) to regulate attachment distress.  That is what this individual does – he clings to women sexually to regulate his anxiety.   So for him the challenge is to connect with the emotions he experienced with his family, represent them as feelings, and reflect on them in the safety of a secure-base relationship. 

His lack of awareness of emotion is not uncommon with preoccupied attachment.  Most emotions are experienced as anger or simply anxiety.  The prefrontal cortex has body-marker cells that register the state of the body.  One hypothesis is that this system allows the brain to know what emotions are being triggered in the organism.  When I asked this patient to focus on his body, it is an attempt to jump-start this recognition system.  Considering how sexually oriented he is, this patient is quite disconnected from his body.  However, with persistence and patience, I usually prevail, and he can identify some physiological changes that are then labeled with a feeling word.  However, in this particular session, I only asked in passing what he was experiencing in his body and did not follow my own advice.  So instead, I started to feel anxious, which led to a mild, but direct confrontation about his behavior with this woman.  I would guess that my anxiety was a combination of his unprocessed emotions, and my fear of his acting out.  My mirror neuron system was probably picking up his fear about acting out and simulated that state in me.  Once I started confronting him about his behavior, his mirror neuron system might have been picking up my fear and anxiety, which probably increased his anxiety even more.  Here he was, stuck in therapy feeling intensely anxious – his only option was to shut down. His reaction to my anxiety was in part, implicit emotional and behavioral memory.  He recalled trying to steer clear of his mother as a child to avoid experiencing the weight of her anxiety.   It was implicit because he wasn’t able to say, “this reminds me of how I felt with my mother” - instead, he just felt and acted like he did with his mother.  At this point in the therapy, on some psychological level, he probably experienced a disconnection in our relationship and a lack of sensitivity from me.  Once I reflected upon and regulated my emotions, I was able to change direction, which allowed him to open up and eventually reflect on his experience.  The danger of not repairing attachment relationship disruptions, such as this, is that it continues to reinforce the implicit negative mental models (memory) that bring about the problems that he was experiencing in the first place.

Suggested Reading

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978).  Patterns of attachment: A psychological study of the strange situation. Hillsdale, N.J.: Erlbaum.

Bowlby, J.. Attachment  and loss, Vol. 1: Attachment. New York: Basic Books; & Hogarth Press. 1969.

Bowlby, J.. Attachment  and loss, Vol. 2: Separation: Anxiety & anger. New York: Basic Books; 1973.

Bowlby, J.. Attachment  and loss, Vol. 3: Loss: Sadness & depression. New York: Basic Books; 1980.

Bowlby, J. (1988). A secure base: Clinical applications of attachment theory. London: Routledge.

Cassidy J. & P. R. Shaver (Eds.)(1999), Handbook of attachment: Theory, research, and clinical applications. New York: Guilford Press.

Damasio, A. (1999). The feeling of what happens: Body and emotion in the making of consciousness. New York: Harcourt Brace.

Fonagy, P.; Target, M.; Gergely, G. and Jurist, E.J.  (2002). Affect Regulation, Mentalization and the Development of the Self. New York: Other Press.

Holmes, J. (2001).  In search of the secure base. London: Routledge.

Main , M., & Goldwyn, R. (1998). Adult attachment classification system. Unpublished manuscript. University of California: Berkeley, CA.

Mikulincer, M., & Shaver, P. R. (2001).  Attachment theory and intergroup bias: Evidence that priming the  secure base schema attenuates negative reactions to out-groups. Journal  of Personality and Social Psychology, 81, 97-115.

Schore, Alan (2003).   Affect regulation and the repair of the self.  New York:   W.W. Norton and Co,

Schore, Alan (2003).  Affect dysregulation and disorders of the self.  New York:   W.W. Norton and Co.

Shaver, Phillip & Mikulincer Mario (2002).  Attachment-Related Psychodynamics.  Attachment and Human Development, 2002, 4: 133-161.

Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape who we are.  New York: Guilford Press.