David Wallin on Attachment in Psychotherapy

This book, Attachment in Psychotherapy, has something of a legendary status in the field it seems to me, so it was on my long-term list of things I knew I must read at some point. But one of the things I learned from Nina Coltart is that clinical work has a way, largely unconsciously, of bumping things up your priority list depending on whom you are treating at any given moment. So with several new cases presenting with what seems to me dismissive and avoidant attachment histories that immediately seemed a threat to treatment even beginning, never mind proceeding successfully, I felt I had to do more work in both attachment and mentalization. So with gratitude and relief I picked up David Wallin's Attachment in Psychotherapy. 

The book begins with the ultimate hook to scholar-clinicians such as I: "How does psychotherapy enable people to change" (p.xi)? Whose blood is immediately not set aracing by such a crucial and intriguing question? 

He immediately posits that an answer to such a question almost certainly has something to do with giving a relational connection and context not unlike that of primary attachment figures in early life, here mentioning to me the surprising claim that Bowlby, famous for his attachment theory, was much more of a clinician than academic, seeing a considerable number of patients who seem to have occupied more time than I ever realized.  

Much of attachment begins at the most primitive, per-verbal levels, and Wallin here calls to mind Christopher Bollas and his notion of the unthought known. This is especially true for disavowed or dissociated experience, which may well end up, Wallin says, being enacted, embodied, or evoked in others. The therapist skilled in mentalization, Wallin says--here tying his own work to that of Fonagy (given his own chapter--#4) which I have also found, and continue to find, so very helpful--will help the patient see these three patterns and begin to reflect on and own them. The therapist who exhibits and encourages such mentalization will likely have a "contagious quality," helping the patient's capacities to expand and grow outside the consulting room.

Wallin also brings in the work of metacognition, which bears a good deal of similarity to mentalization, though the former term was primarily developed in the US while the latter in the UK. In the US Paul Lysaker is most associated with the term in my mind, and his work on metacognition in psychotic disorders informs my own clinical work and has proven very helpful. 

Ch.2, The Foundations of Attachment Theory, covers not just John Bowlby but also Mary Ainsworth's equally important pioneering work here. The gist of this is to show that "an abundance of follow-up studies has tended to show that the attachment patterns of infancy have long-term effects" (p.23). Another number of studies suggest that parents replicate with their infants and children their own attachment patterns and struggles.

Ch.3 focuses directly on Ainsworth, noting that "without a functioning capacity for metacognition, we may for the moment find ourselves in a particular state of mind; lacking such a capacity, it's as if we simply are that state of mind" (p.40). Helping my patients appreciate this has in several cases proven a turning point in treatment. They had hitherto felt helpless in certain affective states, as though controlled by them: Fonagy calls this "embeddeness." But being able to reflect on them, to sit with and observe them as they come and go, has been very helpful. 

As we move into ch.6 of Wallin's book, he makes a useful caveat that perhaps cannot be stated enough: "the fact is that their [patients'] complexity can never be adequately captured by a single descriptor--secure, dismissing, preoccuped, or unresolved" (p.96). Do not, in other words--as I constantly tell my students--expect to see people show up in your consulting room straight out of central casting, with clear, precise, unambiguous clinical presentation allowing you easily and immediately to tick some theoretical or diagnostic box--avoidant! bipolar! OCD! Rare are such patients. 

Ch.8 focuses explicitly on Bollas and the unthought known, emphasizing that patients who cannot put certain things into words will show us by their actions, and that enactments in therapy will also be crucial forms of communication. Here and in many other places in the book, Wallin stresses that with patients whose ability to communicate their struggles in words is limited, "we must tune in to our own subjective experience" (p.129). Such experience includes all of us: Wallin cautions that the "taking cure" must not be limited to "talking heads," but include the whole body. 

Resuming themes of mentalization, Wallin goes on to state quite clearly that "helping patients change their stance toward their own subjective experience depends, in part, on our explicit mentalizing." Lest some think this insufficient--where's the homework? work-sheets? skills building? breathing exercises?--he insists a little further down the same page that "rather than any particular understanding, it is the experience in which the patient feels understood--and inspired to understand herself--that is ultimately most therapeutic" (p.157). 

He resumes this theme later in the book, noting that "for patients who are unresolved the therapeutic relationship is the therapy" (p.244) and such therapy provides an "incremental achievement of a sense of safety in relation to the therapist," and to that extent may heal previously traumatic relationships. Put in classical terminology, psychotherapy that provides "the patient with a secure base" is offering him or her "a corrective relational experience that may be healing in its own right" (p.257).  

Ch.10 brings in the work of Phillip Bromberg, to whom I was recently introduced. His idea of multiple self-states, and of change being something more than a static end-point at which we arrive and stay, has been extremely illuminating for me. Wallin draws on him in this chapter as well as Bion's notion of helping the patient contain "disowned thoughts, feelings, and desires" which can be reintegrated once they have been held in mind by the psychotherapist (p.183). 

Wallin goes on to argue something that I have recently been learning (not without struggle!) from the new book of Karen Maroda (and before her from Nina Coltart and others): the need sometimes less for containment (pace Bion) and more for confrontation and challenge. As Wallin puts it simply, "it must be understood that our patients at times need confrontation more than they need empathy" (p.200). He seems to suggest a little later that this is especially so with those who exibit a predominantly avoidant and dismissive attachment style, clues about which can be found in a tendency to lapse into irrelevancies and to exhibit certain things bodily. For such patients, we need to combine "empathic attunement with confrontation" so that the dismissing patient is led to see "how he gets to us" (p.212). 

We do this, of course, not via a "barrage of honesty" but in a way that the "patient can make use of." In doing so, Wallin cautions toward the end of the book (repeating a theme throughout), we communicate usefully using words, but in other ways as well. If we are not attuned to non-verbal communication, our utility to the patient is going to be limited to just that extent. Thus we must cultivate what he calls "open presence" (310) and earlier "bare attention" (the exact phrase I first learned from Nina Coltart). Such bare attention, Wallin notes at the end of the book, should be offered with in "calm, quiet" ways, quoting one of Freud's technical papers from 1912 (to which Coltart says clinicians should return regularly). 

When we are communicating via words, Wallin hints that it is better to use observation statements than questions: "Generally I prefer to simply comment on what I think I see, letting the meaning emerge from the joint exploration the comment usually elicits" (p.299). 

In the end, we do all this, he says in a neat summary of the book, because "in the new attachment relationship we aim to provide for our patients, repeated experiences of disembedding through mindfulness as well as mentalizing can establish a competing centre of organization in both the mind and brain. In this way such experiences can potentially replace the patient's insecure working models with 'earned secure' ones" (p.337). 

A Note on Bruno Bettelheim on Freud and Man's Soul

I was first introduced to Bruno Bettelheim in high-school by a wonderful English teacher who had first introduced us to Freud and Jung in order to read Robertson Davies' Deptford trilogy. I read with great fascination Bettelheim's The Uses of Enchantment, and in fact had great fun with a friend using that book to analyze various fairy tales we had both grown up hearing and reading.

It was many years later when I thought about Bettelheim again, and read Bettelheim: A Life And A Legacy by Nina Sutton. By then certain egregious details about Bettelheim, in both his Austrian and American periods, were notorious and his reputation nosedived. Sutton's book appeared not long after a lot of those revelations came to light, and attempted reasonably well to grapple with them and to judge him judiciously.

At some point, too, I read his Freud and Man's Soul. This remains a vitally important and likely overlooked book, though my circle of wonderful psychotherapists on Twitter have this week been ordering copies and discussing it, which compelled me to go back and read it again. 

When I first read it, I paid the most attention to Bettelheim's compelling and disturbing examples of the many and serious problems of translation, especially by the Strachey circle, of Freud. I am speculating--but I think on very firm ground in doing so--that these translation decisions were very largely motivated by the politics and early historiography of psychoanalysis (here my debt is chiefly to Paul Roazen's revealing books, including Freud and His Followers as well as others) as well as an overly anxious concern for its reception, and corruption, in American circles. Having seen how the Great War very nearly destroyed psychoanalysis in Mitteleuropa, and how by the 1920s analysts were already emigrating to anglophone countries, Freud (as I've briefly touched upon elsewhere) could already see that psychoanalysis was going to survive most widely in America, but that it would be captured by American physicians and to that extent domesticated and even, one might say, denuded of its more critical and far-reaching potential. 

It would also need--again to an American audience then in increasing thrall to a rising crescendo of American behaviorist psychology--to appear as "scientific" as possible, and to that end a new language had to be invented. This is captured perhaps most notably in what can only be described as the deliberate and ruthless efforts to render the German into abstract pseudo-scientific-sounding English purged of any and all references to the "soul," a point Bettelheim makes with more power than anyone else I have read. I will return to this point presently. 

The Tripartite Model:

The most immediate problems are with the invention of Id, Ego, and Superego (totally foreign to the German, as Bettelheim shows with such devastating cogency, but also to the French: le moi, le ça, le surmoi). If we keep close to Freud's often poetic German (for which, remember, he won the Goethe Prize), then his famous phrase is re-translated by Bettelheim as "Where it was, there should become I."

The problem with these English renderings, Bettelheim shows, is that the bleed out all the deeply personal and individual feelings of das Ich and das Es, introducing a level of estrangement precisely where Freud is attempting to maintain an intimate and personal understanding of the mind. 

Thus a good translation would look like this:

das Ich = the it 

das Es = the I

Über-Ich = the over-I. 

On this latter point Bettelheim says Freud's motive was to stress to us that "it is the person himself who created this controlling institution of the mind" (p.58), thus underscoring again Freud's metapsychological point that the human mind is estranged from itself. (All this is worked out prior to his last phase, the 'cultural phase,' as it were, when he writes of broader estrangement in, e.g., Civilization and its Discontents and Moses and Monotheism.)

The Oedipal Story:

I had forgotten about this part of Bettelheim's book, but on reading it anew saw what a powerful point this was. The translators took it for granted Freud's anglophone readers would understand the details of Oedipus and not need the story presented to them to grasp Freud's point about how little we understand our motives, how blind we often are both to our desires and their sometimes devastatingly destructive consequences (for ourselves and those we hold closest and love most dearly), and how those most blind are often rendered as such because of childhood traumata, all of which the original story of Oedipus make abundantly clear. Oedipus is a deeply wounded child rejected by his family of origin and cast into adoptive and abusive relationships--points we should all have great familiarity with today, making the story as timeless for us as Freud thought it was.

Instead, we get some farrago of nonsense attributed to him. As Bettelheim reminds us, that story is "boys lust after their mothers and want to kill their fathers to have her to themselves for perverse sexual ravishment." This tiresome and transparently tendentious rendering of Freud seems designed only to ensure he is ridiculed ab initio without having to read him any further.  

Freud the Libertine:

Bettelheim opens his book by taking aim directly at another wildly popular but misleading rendering of Freud: that he is some kind of libertine. (Roazen's book Meeting Freud's Family shows in charming detail what rubbish this is.) This has led--in my experience--many religious folks to scathing skepticism or outright dismissal of Freud as some kind of dangerous revolutionary. But this is to miss his point entirely! And that point is that "Know thyself" is not a blank cheque, and does not justify the total absence of (as we would say today) emotional regulation and self-restraint, especially when it comes to erotic desires and sexual practices. 

Freud the Dogmatic Interpretation Machine:

Bettelheim reminds us that problems with translation go back to Freud's most famous book, almost invariably called The Interpretation of Dreams. That title, of course, suggests, not least by using the definite article, that it has oracular powers to divine the meaning of all the productions of the unconscious mind we call dreams. But this is very wide of the mark, Bettelheim says: the German is far more tentative and far less ambitious. Better renderings supplied by Bettelheim would include:

A Search for the Meaning of Dreams (my preference)

or

An Inquiry into the Meaning of Dreams (which Bettelheim prefers).

This corresponds with my reading of Freud's works, and especially his correspondence. Though there are undoubtedly parts of him that occasionally appear as "dogmatic" (but of whom could that not be said at least some of the time? As Adam Phillips has shown, we are all prepared to become unbalanced fanatics about things we truly care about!), I am struck time and again by far more numerous and sincere examples of his hesitancy, his tentativeness, his self-aware putting forth of ideas about which he himself is not completely convinced. Let us recall here how many of his writings were not monographs but essays, and that verb's infinitive in French, of course, means to try.

To pick the most controversial example, the death drive, which appears in Beyond the Pleasure Principle (do read the Broadview translation!): I defy any reader to get through the introduction to that and not be struck repeatedly by how open Freud is to criticism. He seems to go out of his way to underscore his own hesitations, and with good reason. 

The Deletion of the Soul:

"Of all the mistranslations of Freud's phraseology, none has hampered our understanding of his humanistic views more than the elimination of his references to the soul (die Seele)" (p.70). I take this to be the most crucial point of Bettelheim's plaidoyer. On this I think him absolutely correct in ways nobody else has bothered to consider.

In my view (working as I am on a book about the reception of Freudian and psychoanalytic thought in Christian circles), this is the most unforgivable sin committed by virtually all the English translators. For it has fed into the rabid dismissal by Jewish, Muslim, and Christian believers of Freud as a "godless Jew" (to use his own, albeit wry and perhaps ironic, phrase) who, with Marx and Nietzsche (the three "masters of suspicion" famously so called by Ricoeur) is, we are endlessly told, out to "destroy Western civilization" (a phrase whose utterance automatically marks the speaker down as a fundamentally lazy and unimaginative reactionary).  

Bettelheim goes into wonderful detail about how many examples of the soul show up across Freud's writings. I would document some of these, but I have to get off to another meeting, and I want to write about this more in an essay of its own--and finally my long-suffering readers were promised "a note" on the book, not a 10,000 word treatise!

Finis (pro tem).