Jellema, A., 2001. CAT and Attachment Theory: A Reply to Tony Ryle. Reformulation, ACAT News Autumn, p.x.
Tony Ryle's article in the last issue of ACAT News (
) was prompted by Liz Fawkes' editorial in the ACATnews Editorial Summer 2000 edition about "two strands" in CAT, namely Vygotskian/Bakhtinian ideas, and those derived from attachment theory (AT). I am pleased to have the opportunity to respond to Tony's article; my papers on CAT and AT (Jellema, 1999, 2000) were written for a more general psychotherapeutic audience, who may have little knowledge either of AT or of CAT, and some basic exposition was needed. This article addresses briefly some of the CAT-specific issues which Tony Ryle has raised.
While Ryle has sought to develop not just a theory of psychopathology, but also of personality development, attachment theory, as originated by John Bowlby, has more restricted aims. Any theory or model is constructed for a particular purpose; AT seeks primarily to describe and account for the presence of emotional ties between children and their caregivers who offer security and protection from danger, and how and why these ties endure as people develop and grow. Despite Bowlby's initial allegiance to psychoanalysis, and object relations theory in particular, he set about the task of understanding such developmental issues in a way radically different to that of Fairbairn, probably his closest OR counterpart. Bowlby sought to establish a solid scientific underpinning for his work via his own research and promoting that of others, such as Mary Ainsworth, rather than having to rely solely on clinical case material. Tony Ryle writes that "AT has not generated a coherent clinical method", which I see as being down to two main reasons. Firstly, the desire of AT researchers to create a secure empirical base of knowledge, starting with a thorough understanding of the normal development of attachment, has meant that the advancement of clinical aspects of the theory has been fairly slow - since Bowlby, relatively few papers looking at the implications of AT for psychotherapists have been published, and most date from the 1990's. Secondly, attachment theorists would acknowledge that obviously not all that goes wrong with our patients is related to attachment.
Nevertheless, I would like to make the case for the importance of attachment-related issues in many clinical settings. Whereas researchers such as Ainsworth and Mary Main focused in the early days of AT research on largely "normal" samples, more recently the interest has begun to shift towards children and parents "at risk", or presenting to clinicians. In particular, Pat Crittenden has worked with, studied and theorised about children who are neglected, abused and/or actively endangered by their parents -such as we would frequently encounter in the histories of patients labelled "borderline" - hence AT's relevance to current CAT.
AT has produced a formidable body of empirical research over the last 30 years; it is described in the recent "Handbook of Attachment" (Cassidy and Shaver, 1999) which is over 900 pages in length. While the Strange Situation test of attachment in infants and the Adult Attachment Interview (AAI) are much used, there are many other methods for assessing attachment (see e.g. Stein et al (1998) for a thorough review of adult attachment measures). Experimental manipulation of attachment is often not possible, and would be unethical in many circumstances; nonetheless, the use of sophisticated statistical methods gives clear evidence for parent-to-child transmission of attachment patterns. (see e.g. Fonagy et al, 1994).
Tony Ryle's criticisms of the Adult Attachment Interview do have a point. The AAI (in both Main and Goldwyn's, and Crittenden's classification systems) assesses an adult's state(s) of mind with regard to attachment by assignment to one or more categories. As is the case with all such systems, to categorise in this way is to over-simplify, and to turn something active and procedural into something static. Nor is there any doubt that the AAI which began as a developmental psychology research tool is an unwieldy method for assessing patients/clients in everyday use; in my Advanced course research project I showed that a routine CAT reformulation could produce results parallel to those from administering the AAI, and in less time overall (Jellema, 1997).
However, what remains very interesting is the content of the AAI, and the phenomena of attachment theory as a whole, such as the "secure base". Other attachment-related clinical interviews are being developed, e.g. the Attachment Style Interview, (Antonia Bifulco and colleagues) which assesses support in current attachment relationships. Jeremy Holmes is piloting brief attachment-based psychotherapy (BABI), which includes particular attention to issues of loss and separation. The content of the current Psychotherapy File draws on existing theoretical and therapeutic traditions - such as the behavioural and the psychoanalytic - and I have suggested that some attachment concepts can also be useful in CAT in reformulating more accurately procedures and reciprocal roles. In particular, dismissing, preoccupied and unresolved attachment patterns are aspects of many RR's and procedures, which may have major functions as "secondary strategies", developed when the child's primary needs for attachment remain unassuaged (Main, 1990; see also Jellema, submitted m.s.).
Attachment, Dialogism and Cognitivism
Although Ryle has criticised the "cognitivist" assumptions of AT, many therapies developing during the 1970's and '80's drew on various "cognitive" theories, partly as a reaction to the inadequate behaviourist theorising of the 1960's and early '70's. Ryle has acknowledged that CAT as he developed it in the early days also followed such a path. More recently, with the influence of Mikael Leiman, Ryle has moved CAT towards a more dialogical, Vygotskian/Bakhtinian position. While there is no doubt that AT is less dialogically focused than CAT, the differences should not be exaggerated. The earliest attachment research using the Strange Situation (Ainsworth et al, 1978) demonstrated clear associations between mothers' behaviour and attitudes, and the attachment patterns of their infants. (Although Tony Ryle refers to the recent paper by Aitken and Trevarthen (1997) with its critical comment on AT, this paper's sole quoted reference to attachment theory is a very early ethologically-focused paper of Bowlby's from 1958).
Nicola Diamond (1998) makes a good case for the intrinsic intersubjective perspective of attachment theory, which is very close to Tony Ryle's current position. She explicitly rejects the Cartesian position taken in much psychoanalytic writing, of the individual as essentially isolated and split from the world, as does CAT. "For Bowlby, …. What is absolutely primary is interpersonal reality" (p.201).
For its developmental perspective, CAT has drawn largely on research in the area of infant attunement, summarised by Daniel Stern, including the work of e.g. Colwyn Trevarthen. (The concept of attunement is a broader one than that of attachment, and attunement researchers are more likely to study infants in the first six months of life, while early attachments are developing). It is well-acknowledged amongst developmental psychologists that one of the crucial functions of mother-child attunement is to promote attachment; Haft and Slade (1989) demonstrated that it is secure rather than insecure mothers who are able to attune appropriately to their infants' affects. Thus these areas of research are closely linked. The parent's contribution to infant attachment status appears substantial (Main, 1996); parental representations of attachment experiences, as assessed by the AAI, affect how sensitively responsive a parent can be in reacting to the infant's attachment signals (see van Ijzendoorn, 1995).
Returning to the Vygotskian perspective, the incorporation of such ideas into CAT has proved most helpful in understanding the importance of sign mediation in the development of personality and psychopathology. A child's experience is indeed "scaffolded" by the more experienced other. But what happens when that "scaffolding" is profoundly damaged, limited or fragile? What AT can offer - particularly via Crittenden's theorising - are useful accounts of how and why he/she tends to cling to the powerful other who fails to provide an adequately "secure base"; and why under such circumstances he/she may refuse to "explore", not just physically, but also psychologically, as is required in therapy. In attachment theory, security and exploration are reciprocally related, so that only when we feel adequately secure, do we feel free enough to explore the wider environment.
Attachment theory does not just describe behaviour, "representations", or "internalisations" - it also refers to felt bodily experiences of fear, or security and comfort, which are as relevant to therapy as are our more specifically human and culturally-shaped features. AT makes clear that attachment patterns, which begin as properties of relationships, have strong affective features and can become enduring qualities of persons, thus being more resistant to change. In an excellent review paper, Amini et al (1996) describe how early attachment relationships have a major role in organising and regulating neurophysiology in social mammals, ourselves included; patients who have had little effective soothing in such relationships are more likely to find it harder to self-regulate emotion because of the resulting physiological changes which affect the development of the brain and nervous system. The patient who is attached to an abuser may experience intense fear at the very thought of breaking away from a powerful, malignant but also "scaffolding" other. The "care-giver" here may also be an overpowering "predator". In this way, attachment concepts may help us make further sense of comments such as that of Clarke and Llewellyn (1994) who stated in their CAT study of female childhood sexual abuse survivors, that "abuse is a central component of these abused women's construal of self and relationships". Change for such patients may truly involve terror as they come via therapy to "know what they are not supposed to know and feel what they are not supposed to feel" (to paraphrase Bowlby, 1988). In some extreme cases I have worked with, the patient has consciously and actively chosen to remain with the abuser, to avoid an annihilating sense of abandonment.
I think Tony Ryle comes close to this view of Bowlby's in his key 1991 paper on CAT and Vygotskian ideas, in stating, "what the adult cannot let the child do or know today, the child cannot let herself do or know tomorrow". Attachment theory would add to this that there can be major differences in what precisely it is that people can and cannot let themselves and their children do and know about - in particular, the extent to which they can "know" (in the broadest sense) about emotion, especially when it relates to attachment and danger. We should not forget that emotions can signal information of vital importance to our survival, even though there are many instances when in our best interests we should use our highly-developed consciousness to over-ride them. Besides the work of Crittenden, reviewed in my two papers, Roger Kobak and Mary Dozier have researched deactivating (dismissing) and hyperactivating (preoccupied) attachment strategies in insecure individuals, showing how attachment-related affect can be either down- or up-regulated in ways which may be maladaptive (see e.g. Dozier and Kobak, 1992). Such work suggests to me that the "zones of proximal development" should be very different for patients with different attachment strategies; and also within patients with more dissociated (e.g. dismissing/preoccupied) patterns of attachment.
These are just a few of the points I consider attachment theory has to offer CAT - so why should not cognitive analytic theory be able to influence our understanding of attachment? After all, true dialogue works both ways. Each tradition has a considerable body of knowledge that can help inform the other; many of the current areas of disagreement may turn out to be attributable to a lack of knowledge on each side, provided we acknowledge that in therapy, as in life, there can be "no final word". Can a synthesis be created from this dialectic?
To conclude, then, if there are such different "strands" within CAT, I do not see CAT as likely to "unravel" - to my mind they are different traditions which can gradually " weave together", ultimately to form a richer "tapestry".
Ainsworth, M.D.S., Blehar, M., Waters, E. and Wall, S. (1978) Patterns of attachment: a psychological study of the strange situation. Hillsdale, New Jersey: Erlbaum.
Aitken, K.J. and Trevarthen, C. (1997) Self/other organisation in human psychological development. Development and Psychopathology, vol. 9, pp. 653-678.
Amini, F., Lewis, T., Lannon, R., Louie, A., Baumbacher, G., McGuinness, T. and Schiff, E.Z. (1996) Affect, attachment, memory: contributions toward psychobiologic integration. Psychiatry, vol. 59, pp. 213-239.
Bowlby, J. (1988) A secure base: clinical applications of attachment theory. London: Routledge.
Cassidy, J. and Shaver, P. (eds.) (1999) Handbook of attachment: theory, research and clinical applications. London: Guilford.
Clarke, S. and Llewellyn, S. (1994) Personal constructs of survivors of childhood sexual abuse receiving cognitive analytic therapy. British Journal of Medical Psychology, vol. 67, pp. 273-289.
Diamond, N. (1998) On Bowlby's legacy: further explorations. Ch. 15 in: M. Marrone, Attachment and Interaction. Pp. 193-214. London: Jessica Kingsley.
Dozier, M. and Kobak, R.R. (1992) Psychophysiology in attachment interviews: converging evidence for deactivating strategies. Child Development, vol.63, pp. 1473-1480.
Fonagy, P., Steele, M., Steele, H., Higgitt, A. and Target, M. (1994) The theory and practice of resilience. Journal of Child Psychology and Psychiatry, vol. 35, pp. 231-257.
Haft, W.L. and Slade, A. (1989) Affect attunement and maternal attachment: a pilot study. Infant Mental Health Journal, vol. 10, pp. 157-172.
Van IJzendoorn, M.H. (1995) Adult attachment representations, parental responsiveness, and infant attachment: a meta-analysis on the predictive validity of the Adult Attachment Interview. Psychological Bulletin, vol. 117, pp. 387-403.
Jellema, A. (1997) Two single case studies examining the use of the Adult Attachment Interview as an assessment tool and outcome measure in CAT. London: UMDS/Guy's, unpublished research project.
Jellema, A. (1999)
. Clinical Psychology and Psychotherapy, vol. 6, pp. 16-28.
Jellema, A. (2000) Insecure attachment states: their relationship to borderline and narcissistic personality disorders and treatment process in cognitive analytic therapy. Clinical Psychology and Psychotherapy, vol. 7, pp.138-154.
Jellema, A. (submitted m.s.) Dismissing and preoccupied insecure attachment and procedures in CAT: some implications for CAT practice. (Clinical Psychology and Psychotherapy).
Main, M. (1990) Cross-cultural studies of attachment organisation: recent studies, changing methodologies, and the concept of conditional strategies. Human Development, vol. 33, pp. 48-61.
Main, M. (1996) Introduction to the special section on attachment and psychopathology: overview of the field of attachment. Journal of Consulting and Clinical Psychology, vol. 64, pp. 237-243.
Stein, H., Jacobs, N.J., Ferguson, K.S., Allen, J.G. and Fonagy, P. (1998) What do adult attachment scales measure? Bulletin of the Menninger Clinic, vol. 62, pp. 33-82.
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