By Alan Eppel
Posted with permission from New Therapist issue no.84 March-April 2013
The interplay of love and loss is the
central dynamic in the human story. The longing for love and the pain of its
loss are the most deeply felt of human emotions. This should not surprise us.
The drive to attach to another is fundamental and primary in human nature. It
is, after all, a matter of life and death for, without attachment, the human
infant faces the prospect of isolation, exposure, starvation and death.
Attachment
and love
Over the course of
geologic time, mammals have evolved a neurobiological program to bring infant
and mother into proximity with one another. This mother-infant proximity
system, known as attachment, is inborn. Reciprocally, the mother is genetically
equipped with emotional systems to provide care-giving and nurturing. The drive
to attach stays with us throughout life. It determines the nature of our
relationships. The subjective experience of feeling positively attached to
another may be seen to constitute a large part of what we refer to colloquially
as “love”. The converse state is separation, which is accompanied by sadness
and despair.
More than half a century after John Bowlby's
radical transformation of the object-relations paradigm through the lens of
attachment theory, we have come to recognize the enormous importance of his
thinking as a model for the practice of dynamic and emotion focused
psychotherapies. Many of Bowlby's key concepts had their precursors in the work
of his colleagues of the object-relations school in England. Fairbairn's
fundamental principle that the ego is “object-seeking” is directly analogous to
the attachment drive. Michael Balint's “primary object love” also identifies
this universal human striving. Bowlby translated these psychoanalytic metaphors
into thelanguage and science of ethology [the science of animal behaviour].
The attachment system is
a reciprocal interacting program between mother and infant. There are three
overarching components of attachment: proximity- seeking; separation distress
and secure base. The infant has the in-built circuitry to seek closeness to the
primary attachment figure and to experience separation distress when the mother
is not close by. The mother has corresponding programming to respond to the
cries of the distressed infant.
Jaak Panksepp (1998) has
elucidated the underlying neurobiological mechanisms involved in the attachment
system. He describes the social bonding and separation distress system as one
of seven core emotional systems that have their origins in the sub-cortical
areas in the brains of mammals. He has termed the maternal system the
“CARE/Nurturance system” and the separation as the “PANIC”or GRIEF/DISTRESS”
system (Panksepp, 2009).
Secure attachment
develops when the mother is responsive and attuned to her infant's needs for
affection, touch, food, and removal of discomfort. Attunment refers to the
mutually empathic interaction between mother and infant that is facilitated by
face-to-face interaction, smiling, eye gaze, skin-to-skin contact, touch and
rhythmic speech.
When close to the mother, the infant experiences positive
feelings of satiety, pleasure and feelings of inner goodness. When the mother
or other primary attachment figure is able to consistently meet the infant’s
need, this sense of inner goodness becomes the foundation for healthy identity
development.
The infant's emotional state is determined to a large extent by
the proximity and responsiveness of the mother. Alan Sroufe (1996) has captured
this in the idea that attachment is the ”dyadic regulation of emotion”. The
dyadic relationship can soothe distress and amplify positive emotions of joy
and exhilaration or, conversely, exacerbate states of distress and discomfort.
Schore (2001) has postulated that the quality of attachment
relationships is particularly critical in the first three years of life and has
a major impact on brain development, particularly with regard to the right
hemisphere and the limbic system.
It is not necessary that
the primary caregiver meets the infant's needs all of the time. In fact a 100%
response rate would not be optimal for development, as the infant needs to
develop some tolerance to being alone. Winnicott referred to “good-enough
mothering”, which is the amount of sensitivity and responsiveness that ensures
healthy psychological development of thechild.
Edward Tronick (1998)
has furthered our understanding of this by identifying three types of mother
baby interaction:
The first of these is coordinated interaction, when mother and
baby are engaged, and behaviour and affect are responsive and matching. This is
associated with positive emotion in the infant.
Secondly, he identifies
a mis-coordinated interaction - a mismatch or lack of attunement. When there is
a misalignment, the infant's needs are not the met, resulting in the experience
of the pain of separation, fear, discomfort, and inner feelings of badness.
If misattunement is too
frequent, the child grows up with insecure attachment, an inner sense of
Features
Attachment and loss
badness and unlovableness that forms the
basis of his or her personality. However a certain amount of miscoordination
may be required for the infant to be able to differentiate himself as separate
from the mother. [Cf. Winnicott, 1965].
Thirdly, Tronick speaks of “repair”, the movement from a
mis-coordinated state back to a coordinated state, when mother and infant again
interact in a mutually resonant way. This may lead to soothing and elimination
of disturbing emotions and the return of positive feelings and sensations.
The infant's repeated experience of repair leads to a
positive inner sense of self, an expectation that things can be repaired.
Repair of empathic misattunement facilitates secure attachment. Repair may also
promote the acquisition of the capacity to endure deprivation and hardship—that
is, the development of psychological resilience.
The Attachment system is an emotional operating system that
is comprised of two aspects:
Firstly the behavioural or action components and secondly
the inner feeling states that trigger and accompany these.
When
the infant is apart from the mother he experiences the feeling states of
sadness or depression, which lead to various behaviours, such as crying,
searching and motor agitation. In response the mother experiences the feelings
of concern and the desire to take care of the baby.
In
the infant, the feeling that corresponds to secure attachment is the feeling of
being loved. For the mother, the reciprocal inner state is the feeling of
loving. Dopamine and oxytocin are two brain chemicals that are intricately
involved in the control and experience of attachment and love (Panksepp 1998,
p.252).
When the maternal environment is often
misattuned and unresponsive, the infant experiences too much separation, with
the accompanying affects of sadness, grief or depression. A child in this
situation may grow up with a sense of being unloved and unlovable.
Physical and sexual abuse by
caregivers are two of the most extreme forms of failed attachment. Abused
children grow up with extreme insecurity and mistrust in relationships. Instead
of healthy emotion regulation via the attachment dyad these children experience
the terror and extreme psychological pain of abuse. They grow up with the
inability to self-soothe and modulate their emotions. They display marked
affective instability or, in Marsha Linehan's terms, severe emotion
dysregulation (Linehan, 1993). Children with profoundly disturbed attachment
relationships develop feelings of intense aloneness. Their adult attachments are
insecure and are often characterised by avoidance or anxious preoccupation.
Such adult individuals may attract diagnoses of complex posttraumatic stress
disorder and/or borderline personality disorder.
A child
growing up in a non-loving environment may be forced to suppress his true
feelings. This often results from the need to accommodate a demanding, abusive
parent. The child is forced to suppress his or her authentic emotions and
thoughts. This leads to the emergence of a false self (Winnicott, 1965).
Separation
and loss
Separation is the converse of attachment; sorrow is the converse
of love. The intensity of sorrow is proportional to the intensity of the
attachment bond and its felt component, love.
The attachment system is a survival system. It follows that loss
of attachment or the threat of loss of the attachment object leads to fear.
Freud put it well:
“We are never so
defenseless against suffering as when we love, never so forlornly unhappy as when
we have lost our love object or its love” (Freud 1930a, p.82).
Separation, the loss of
attachment, is the primal source of anxiety. The fear of separation and the
fear of death are at various points in the life cycle inextricably bound. Death
is the ultimate separation. Death is the final loss of attachment ties. Erich
Fromm recognized the significance of man’s essential separation and isolation:
“The awareness of his
aloneness and separateness, of his helplessness before the forces of nature and
of society, all this makes his separate disunited existence an unbearable
prison. The experience of separateness arouses anxiety; it is indeed the source
of all anxiety.” (Fromm, 1956, p.7)
Infants facing loss respond with protest and attempts to recover
the mother (Bowlby 1980 p.9). the infant becomes distressed, cries, exhibits
motor agitation and searches the environment for his mother. The infant has an
intense longing for the mother but if she does not return the infant loses
hope, becomes inactiveand withdraws. He experiences “unutterable misery” and
despair.(Bowlby 1980). Above all there is a feeling of extreme abandonment and
aloneness. Adults confronted with separation or loss through death experience
the same emotions: Protest , despair, withdrawal, feelings of aloneness. This
can be so intense that that the sufferer may contemplate suicide. Attachment is
a life preserving system. Loss of attachment is life threatening.
Features
Attachment and loss
In the protest phase anger can be expressed verbally or
violently. Men with extremes of preoccupied attachment are possessive and
abusive of the love object. They may exhibit extreme rage after separation and
pose a risk of homicide directed against the spouse and/or new mate: “if I
can't have you no one can”. This is one scenario of homicide-suicide.
Our sense of self and identity evolve through our attachment
relationships in childhood. Patients with insecure attachment such as those
with borderline personality disorder, often describe feeling “invisible”,
unseen. Loss or abandonment may lead to suicide. It is too unbearable to be
alone.
Bereavement often entails a loss of identity, expressed by those
widowed after long marriages. Despair and loss of the will to live may follow.
Without the other, the “Thou” in the “I-Thou” relationship ( Buber 1970), there
is no “I”.
Implications
for psychotherapy
Love and loss are central in life and constitute recurring
themes in psychotherapy. Psychotherapy is an attempt to reach across the space
between attachment and loss in an effort to heal.
Bowlby recognized that his theory had applications to
psychotherapy (Bowlby 1977): foremost among these were to provide the patient
with a secure base from which to explore relationships, and to help the patient
to appreciate how his current difficulties may be understood in terms of his
attachment relationships.
Attachment theory has become an essential
component in many psychotherapies. It has been extended into
psychoanalytic practice by a number of contemporary therapists and
‘
Psychotherapy is an attempt to reach across the space between attachment and loss in an effort to heal.
’
researchers (Fonagy
2001).
Accelerated Experiential
Dynamic Psychotherapy(AEDP), developed by New York Psychologist Diana Fosha,
explicitly applies concepts from attachment theory and research. AEDP therapy
begins by establishing safety, a secure base to counteract the patient’s feelings
of aloneness.
Fosha argues that
interpretation and insight do not lead to change but, rather, it is the
experience of previously “unbearable affect” in the present moment within the
securely attached dyadic relationship with the therapist that is
transformative. This type of psychotherapy involves us reaching across the
divide that separates the therapist from the patient—reaching across to attach
and to mitigate the pains of loss and separation.
Fosha integrates the
ideas of many pioneer's in the field. There is a strong influence of Winnicott
in some of her overarching views of the psychotherapeutic relationship. She
trained with Habib Davanloo, who had developed an intensive form of short-term
dynamic psychotherapy. Davanloo's methodinvolves breaking through to
unconscious material by forcefully challenging defenses. Fosha crafted a very
different approach to get past defenses to “core affects”. Adopting the
attachment paradigm, rather than confrontation, Fosha employsempathic
attunement. This requires moment-to-moment trackingand paying exquisite
attention to minute signs of affective shift: body posture; facial expression;
the slightest hint of a tear or a smile.
Fosha has also
incorporated technical aspects from Leslie Greenberg's Emotion FocusedTherapy,
David Malan's Brief Psychotherapy, and Michael Alpert's Accelerated Empathic
Therapy, among others. AEDP is not exclusionary and integrates many components
from emerging psychotherapies. Conversely many of its therapeutic techniques
can be incorporated into other approaches.
AEDP is accelerated
because moment-to-moment tracking andexplicit empathy lead to rapid access to
core affects and associated memories. It is experiential because the focus is
on the experience of emotion in the present moment and staying with and
processing it. It is dynamic in its use of defense work and concepts of
self-other representations.
Fosha
(2000) identifies three fluid states in the course of the psychotherapeutic
interview:
In state one, when
patients present, they are in distress. They display anxiety, disturbing
symptoms and defensive operations. Distress may be the result of the failure of
the defenses and be manifested in dysregulated affectsor inhibiting affects,
such as anxiety or shame. Defenses block access to core affect and lead to
maladaptive behaviours. Several processes are used at this point: moment-tomoment
tracking; dyadic regulation of affect, which is facilitated by the therapist
responding in matching tone and rhythm; the expression of empathy, compassion,
warmth and
Features
Attachment and loss
appreciation; and selective therapist disclosure of the
positive impact the patient has on the therapist. This facilitates the patient
“dropping down” to state two.
In
state two the patient is in touch with core affects and experiences deep
visceral emotion. Core affects include grief, sadness, anger, rage, fear, joy
and excitement. Transformation to state two is analogous to Davanloo's concept
of “unlocking the unconscious” (Davanloo 1990). In state two, previously
inaccessible feelings, thoughts and memories emerge.The therapist helps the patient
to stay with these emotions by means of empathy, validation and dyadic
regulation of affect. Painful core affects are connected with trauma, loss and
disappointment.
State three is characterised by the emergence of a
different set of affects: the healing affects of gratitude, tenderness and
feeling moved; the mastery affects of pride and joy. The therapeutic
intervention at this stage consists of metatherapeutic processing, a powerful
intervention that can be incorporated into other dynamic methods of psychotherapy.
Metaprocessing consists of patient and therapist reflecting together on the
patient’s experience of the interaction with the therapist. This promotes a
deepening of the affective experience and processing by the “cognitive” left
brain. Metaprocessing also allows for
repair of empathic misattunements, which serves to powerfully deepen the
therapeutic relationship and ideally will lead to state four, the core state.
The core state is an experience of openness and connection; feelings of vitality
and authenticity. This can be viewed as making contact with the “true self”
(Winnicott 1965b).
At this point in the therapeutic process the patient and
therapist feel an authentic sense of connection: the true self in relation with
the true other. There is a felt sense of deep contact with one’s true inner
experience, a sense of authenticity, calmness, clarity and self-compassion.
Martin Buber (1961) describes the true encounter as occurring fully in a
spaceless and timeless present, between one whole human being and another. The
essence of humanity is defined by this dialogue, the true encounter, where deep
connects with deep.
References:
Bowlby,
J ( 1980) Attachment and Loss Vol 3 Loss. New York. Basic Books.
Bowlby,
J (1977) The Making and Breaking of Affectional Bonds British J. Psychiatry
130,421-31
Buber,
M (1970) I and Thou. New York. Charles Scribner's Sons
Buber,
M (1961) Between Man and Man. London. Fontana
Davanloo,
H (1990) Unlocking the unconscious: Selected papers of Habib Davanloo.
New York. Wiley
Fonagy,
P (2001) Attachment Theory and Psychoanalysis. New York. Other Press
Fosha, D (2000) The Transforming Power of
Affect. New York. Basic Books.
Freud, S (1923) The Ego and The Id.
S.E. 19. London. Hogarth
Fromm,
E (1956) The Art of Loving. New York . Bantam Books
Linehan, M (1993) Cognitive-BehavioralTreatment
of Borderline Personality Disorder.
New York: Guilford Press
Panksepp,
J (1998) Affective Neuroscience: the foundations of human and animal
emotions. Oxford University Press
Panksepp,
J (2003) Feeling the Pain of Social Loss. Science v.302 237-239
Panksepp, J (2009) Brain
Emotional Systems and Qualities of Mental Life: From Animal Models of Affect to
Implications for Psychotherapeutics, in Fosha D, Siegel D, Solomon M: The
Healing Power of Emotion. New York. Norton
Schore,
A. N. (2001). Effects of a secure attachment relationship on right brain
development, affect regulation and infant mental health. Infant Mental
Health Journal, 22, 7-66.
Sroufe,
A (1996) Emotional development: the organization of emotional life in the
early years. New York. Cambridge University Press
Tronick,
E (1998) Dyadically Expanded States of Consciousness and the Process of
Therapeutic Change. Infant Mental Health Journal. Vol. 19, 290-299
Winnicott, D. W. (1965a) The Maturational
Processes and the Facilitating Environment: Studies in the Theory of Emotional
Development. London Hogarth
Winnicott, D (1965b) Ego
distortion in terms of true and false self, in The Maturational Processes and
the Facilitating Environment: Studies in the Theory of Emotional Development.
London Hogarth
Alan Eppel is a psychiatrist and
psychotherapist. He is an Associate Clinical Professor in the Department of
Psychiatry and Behavioural Neurosciences McMaster University Hamilton, Ontario.
Author
of “Sweet Sorrow: Love, Loss and Attachment in Human Life”. He has recently undertaken training in
Accelerated Experiential Dynamic Psychotherapy.
