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).