02 - 2.2 Attachment Theory

2.2 Attachment Theory

deficits or constrictions. For example, can the person regulate activity and sensations, relate to others, read nonverbal affective symbols, represent experience, build bridges between representations, integrate emotional polarities, abstract feelings, and reflect on internal wishes and feelings? From a developmental point of view, the integral parts of the therapeutic process include learning how to regulate experience; to engage more fully and deeply in relationships; to perceive, comprehend, and respond to complex behaviors, and interactive patterns; and to be able to engage in the ever-changing opportunities, tasks, and challenges during the course of life (e.g., adulthood and aging) and, throughout, to observe and reflect on one’s own and others’ experiences. These processes are the foundation of the ego, and more broadly, the personality. Their presence constitutes emotional health and their absence, emotional disorder. The developmental approach describes how to harness these core processes and so assist the patients in mobilizing their own growth. REFERENCES Bond T. Comparing decalage and development with cognitive developmental tests. J Appl Meas. 2010;11(2):158. Boom J. Egocentrism in moral development: Gibbs, Piaget, Kohlberg. New Ideas Psychol. 2011;29(3):355. Dickinson D. Zeroing in on early cognitive development in schizophrenia. Am J Psychiatry. 2014;171:9–12. Greenspan S, Curry J. Piaget and cognitive development. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. 1. Philadelphia: Lippincott Williams & Wilkins; 2009:635. Harris PL. Piaget on causality: The Whig interpretation of cognitive development. Br J Psychol. 2009;100(S1):229. Houdé O, Pineau A, Leroux G, Poirel N, Perchey G, Lanoë C, Lubin A, Turbelin MR, Rossi S, Simon G, Delcroix N, Lamberton F, Vigneau M, Wisniewski G, Vicet JR, Mazoyer B. Functional magnetic resonance imaging study of Piaget’s conservation-of-number task in preschool and school-age children: A neo-Piagetian approach. J Exp Child Psychol. 2011;110(3):332 Mesotten D, Gielen M, Sterken C, Claessens K, Hermans G, Vlasselaers D, Lemiere J, Lagae L, Gewillig M, Eyskens B, Vanhorebeek I, Wouters PJ, Van den Berghe G. Neurocognitive development of children 4 years after critical illness and treatment with tight glucose control: A randomized controlled trial. JAMA. 2012;308(16):1641. Whitbourne SK, Whitbourne SB. Piaget’s cognitive-developmental theory. In: Adult Development and Aging: Biopsychosocial Perspectives. 4th ed. Hoboken: John Wiley & Sons, Inc.; 2011:32. 2.2 Attachment Theory ATTACHMENT AND DEVELOPMENT Attachment can be defined as the emotional tone between children and their caregivers and is evidenced by an infant’s seeking and clinging to the caregiving person, usually the mother. By their first month, infants usually have begun to show such behavior, which is designed to promote proximity to the desired person. Attachment theory originated in the work of John Bowlby, a British psychoanalyst (1907–1990) (Fig. 2.2-1). In his studies of infant attachment and separation, Bowlby

pointed out that attachment constituted a central motivational force and that mother– child attachment was an essential medium of human interaction that had important consequences for later development and personality functioning. Being monotropic, infants tend to attach to one person; but they can form attachments to several persons, such as the father or a surrogate. Attachment develops gradually; it results in an infant’s wanting to be with a preferred person, who is perceived as stronger, wiser, and able to reduce anxiety or distress. Attachment thus gives infants feelings of security. The process is facilitated by interaction between mother and infant; the amount of time together is less important than the amount of activity between the two. FIGURE 2.2-1 John Bowlby (1907–1990). The term bonding is sometimes used synonymously with attachment, but the two are different phenomena. Bonding concerns the mother’s feelings for her infant and differs from attachment. Mothers do not normally rely on their infants as a source of security, as is the case in attachment behavior. Much research reveals that the bonding of mother to infant occurs when there is skin-to-skin contact between the two or when other types of contact, such as voice and eye contact, are made. Some workers have concluded that a mother who has skin-to-skin contact with her baby immediately after birth shows a

stronger bonding pattern and may provide more attentive care than a mother who does not have this experience. Some researchers have even proposed a critical period immediately after birth, during which such skin-to-skin contact must occur if bonding is to take place. This concept is much disputed: Many mothers are clearly bonded to their infants and display excellent maternal care even though they did not have skin-to-skin contact immediately postpartum. Because human beings can develop representational models of their babies in utero and even before conception, this representational thinking may be as important to the bonding process as skin, voice, or eye contact. Ethological Studies Bowlby suggested a Darwinian evolutionary basis for attachment behavior; namely, such behavior ensures that adults protect their young. Ethological studies show that nonhuman primates and other animals exhibit attachment behavior patterns that are presumably instinctual and are governed by inborn tendencies. An example of an instinctual attachment system is imprinting, in which certain stimuli can elicit innate behavior patterns during the first few hours of an animal’s behavioral development; thus, the animal offspring becomes attached to its mother at a critical period early in its development. A similar sensitive or critical period during which attachment occurs has been postulated for human infants. The presence of imprinting behavior in humans is highly controversial, but bonding and attachment behavior during the first year of life closely approximate the critical period; in humans, however, this period occurs over a span of years rather than hours. Harry Harlow. Harry Harlow’s work with monkeys is relevant to attachment theory. Harlow demonstrated the emotional and behavioral effects of isolating monkeys from birth and keeping them from forming attachments. The isolates were withdrawn, unable to relate to peers, unable to mate, and incapable of caring for their offspring. PHASES OF ATTACHMENT In the first attachment phase, sometimes called the preattachment stage (birth to 8 or 12 weeks), babies orient to their mothers, follow them with their eyes over a 180-degree range, and turn toward and move rhythmically with their mother’s voice. In the second phase, sometimes called attachment in the making (8 to 12 weeks to 6 months), infants become attached to one or more persons in the environment. In the third phase, sometimes called clear-cut attachment (6 through 24 months), infants cry and show other signs of distress when separated from the caretaker or mother; this phase can occur as early as 3 months in some infants. On being returned to the mother, the infant stops crying and clings, as if to gain further assurance of the mother’s return. Sometimes, seeing the mother after a separation is sufficient for crying to stop. In the fourth phase (25 months and beyond), the mother figure is seen as independent, and a more complex relationship between the mother and the child develops. Table 2.2-1 summarizes the development of normal attachment from birth through 3 years.

Table 2.2-1 Normal Attachment

Mary Ainsworth Mary Ainsworth (1913–1999) was a Canadian developmental psychologist from the University of Toronto. She described three main types of insecure attachment: insecure– avoidant, insecure–ambivalent, and insecure–disorganized. The insecure–avoidant child, having experienced brusque or aggressive parenting, tends to avoid close contact with people and lingers near caregivers rather than approaching them directly when faced with a threat. The insecure–ambivalent child finds exploratory play difficult, even in the absence of danger, and clings to his or her inconsistent parents. Insecure–disorganized children have parents who are emotionally absent with a parental history of abuse in their childhood. These children tend to behave in bizarre ways when threatened. According to Ainsworth, disorganization is a severe form of insecure attachment and a possible precursor of severe personality disorder and dissociative phenomena in adolescence and early adulthood. Mary Ainsworth expanded on Bowlby’s observations and found that the interaction between the mother and her baby during the attachment period significantly influences the baby’s current and future behavior. Patterns of attachments vary among babies; for example, some babies signal or cry less than others. Sensitive responsiveness to infant

signals, such as cuddling a crying baby, causes infants to cry less in later months, rather than reinforcing crying behavior. Close bodily contact with the mother when the baby signals for her is also associated with the growth of self-reliance, rather than a clinging dependence, as the baby grows older. Unresponsive mothers produce anxious babies; these mothers often have lower intelligence quotients (IQs) and are emotionally more immature and younger than responsive mothers. Ainsworth also confirmed that attachment serves to reduce anxiety. What she called the secure base effect enables children to move away from attachment figures and to explore the environment. Inanimate objects, such as a teddy bear and a blanket (called the transitional object by Donald Winnicott), also serve as a secure base, one that often accompanies them as they investigate the world. Strange Situation. Ainsworth developed strange situation, the research protocol for assessing the quality and security of an infant’s attachment. In this procedure, the infant is exposed to escalating amounts of stress; for example, the infant and the parent enter an unfamiliar room, an unfamiliar adult then enters the room, and the parent leaves the room. The protocol has seven steps (Table 2.2-2). According to Ainsworth’s studies, about 65 percent of infants are securely attached by the age of 24 months. Table 2.2-2 The Strange Situation ANXIETY Bowlby’s theory of anxiety holds that a child’s sense of distress during separation is perceived and experienced as anxiety and is the prototype of anxiety. Any stimuli that alarm children and cause fear (e.g., loud noises, falling, and cold blasts of air) mobilize signal indicators (e.g., crying) that cause the mother to respond in a caring way by

cuddling and reassuring the child. The mother’s ability to relieve the infant’s anxiety or fear is fundamental to the growth of attachment in the infant. When the mother is close to the child and the child experiences no fear, the child gains a sense of security, the opposite of anxiety. When the mother is unavailable to the infant because of physical absence (e.g., if the mother is in prison) or because of psychological impairment (e.g., severe depression), anxiety develops in the infant. Expressed as tearfulness or irritability, separation anxiety is the response of a child who is isolated or separated from its mother or caretaker. It is most common at 10 to 18 months of age and disappears generally by the end of the third year. Somewhat earlier (at about 8 months) stranger anxiety, an anxiety response to someone other than the caregiver, appears. Signal Indicators Signal indicators are infants’ signs of distress that prompt or elicit a behavioral response in the mother. The primary signal is crying. The three types of signal indicators are hunger (the most common), anger, and pain. Some mothers can distinguish between them, but most mothers generalize the hunger cry to represent distress from pain, frustration, or anger. Other signal indicators that reinforce attachment are smiling, cooing, and looking. The sound of an adult human voice can prompt these indicators. Losing Attachments Persons’ reactions to the death of a parent or a spouse can be traced to the nature of their past and present attachment to the lost figure. An absence of demonstrable grief may be owing to real experiences of rejection and to the lack of closeness in the relationship. The person may even consciously offer an idealized picture of the deceased. Persons who show no grief usually try to present themselves as independent and as disinterested in closeness and attachment. Sometimes, however, the severing of attachments is traumatic. The death of a parent or a spouse can precipitate a depressive disorder, and even suicide, in some persons. The death of a spouse increases the chance that the surviving spouse will experience a physical or mental disorder during the next year. The onset of depression and other dysphoric states often involves having been rejected by a significant figure in a person’s life. DISORDERS OF ATTACHMENT Attachment disorders are characterized by biopsychosocial pathology that results from maternal deprivation, a lack of care by, and interaction with, the mother or caregiver. Failure-to-thrive syndromes, psychosocial dwarfism, separation anxiety disorder, avoidant personality disorder, depressive disorders, delinquency, academic problems, and borderline intelligence have been traced to negative attachment experiences. When maternal care is deficient because (1) a mother is mentally ill, (2) a child is

institutionalized for a long time, or (3) the primary object of attachment dies, children sustain emotional damage. Bowlby originally thought that the damage was permanent and invariable, but he revised his theories to take into account the time at which the separation occurred, the type and degree of separation, and the level of security that the child experienced before the separation. Bowlby described a predictable set and sequence of behavior patterns in children who are separated from their mothers for long periods (more than 3 months): protest, in which the child protests the separation by crying, calling out, and searching for the lost person; despair, in which the child appears to lose hope that the mother will return; and detachment, in which the child emotionally separates himself or herself from the mother. Bowlby believed that this sequence involves ambivalent feelings toward the mother; the child both wants her and is angry with her for her desertion. Children in the detachment stage respond in an indifferent manner when the mother returns; the mother has not been forgotten, but the child is angry at her for having gone away in the first place and fears that she will go away again. Some children have affectionless personalities characterized by emotional withdrawal, little or no feeling, and a limited ability to form affectionate relationships. Anaclitic Depression Anaclitic depression, also known as hospitalism, was first described by René Spitz in infants who had made normal attachments but were then suddenly separated from their mothers for varying times and placed in institutions or hospitals. The children became depressed, withdrawn, nonresponsive, and vulnerable to physical illness, but they recovered when their mothers returned or when surrogate mothering was available. CHILD MALTREATMENT Abused children often maintain their attachments to abusive parents. Studies of dogs have shown that severe punishment and maltreatment increase attachment behavior. When children are hungry, sick, or in pain, they too show clinging attachment behavior. Similarly, when children are rejected by their parents or are afraid of them, their attachment may increase; some children want to remain with an abusive parent. Nevertheless, when a choice must be made between a punishing and a nonpunishing figure, the nonpunishing person is the preferable choice, especially if the person is sensitive to the child’s needs. PSYCHIATRIC APPLICATIONS The applications of attachment theory in psychotherapy are numerous. When a patient is able to attach to a therapist, a secure base effect is seen. The patient may then be able to take risks, mask anxiety, and practice new patterns of behavior that otherwise might not have been attempted. Patients whose impairments can be traced to never having made an attachment in early life may do so for the first time in therapy, with salutary