Treating Attachment Disorders: From Theory to Therapy
by Karl Heinz Brisch
translated from the German by Kenneth Kronenberg
Published by The Guilford Press, 2002
Attachment theory and research have greatly enhanced our understanding of the role of parent–child relationships in the development of psychopathology. Yet until now, little has been written on how an attachment perspective can be used to actively inform psychotherapeutic practice. In this invaluable work, Karl Heinz Brisch presents an attachment-oriented framework for assessing and treating patients of all ages. Rich, extended case examples that demonstrate the ways attachment-oriented interventions can effectively be used to treat a wide range of patients form the core of the book. The study below illustrates Brisch's general approach:
Severe psychosomatic illnesses among adolescents, such as neurodermatitis, anorexia nervosa, bulimia, Crohn's Disease, and ulcerative colitis place a great strain on family members. Severe physical symptoms often demand somatic treatment in parallel with psychotherapy, and may include monitoring of blood values, weight fluctuations, and so on. An adolescent in circumstances like this is tied into a treatment regime, that may satisfy his attachment needs, but not his wish for autonomy. From an attachment theory perspective, it is the therapist's task to help these adolescents find a helpful balance between attachment and autonomy.
Initial Presentation and Symptoms
Mr. O. calls and asks in a subdued and timid voice whether he can do therapy with me. He doesn't exactly know what "therapy" is; his family doctor referred him to me. He says that he has many problems, but that he can't talk about them on the phone.
A very tall, slim, nineteen-year-old man, his head pulled between his shoulders as he enters the door, comes to the initial consultation. Timidly he takes only my fingertips as we shake hands. I notice that he has a bandage on his left hand. He looks at me through his steel-rimmed glasses with a mixture of distrust and expectation. He waits for a long time until I finally take the initiative and begin to ask him questions.
He tells me that he's coming now because he has major problems with his girlfriend. She's actually very nice; she takes care of him, and he gets along with her quite well; the day-to-day relationship is not a problem. They have been living together for six months. Although he had yearned for this, he finds that he often can't endure being with her. He becomes aggressive, and has to leave the apartment because he fears an "explosion." Violent thoughts like this come to him particularly when they are "very close," or being intimate with each other. He is very unhappy about this and doesn't know what to do. His girlfriend interprets his behavior as rejection, which makes him very sad. He has had skin problems for many years, and they have recently "blossomed." Because his skin is "open and bloody" in many areas, he is currently unable to work.
Mr. O. was the eighth and last child in a very large family. He himself believes that his mother "had actually had enough after six." He remembers the names, ages, and birthdays of his siblings only with a great deal of effort, and he is not at all sure whether what he says is correct. He states that everything in his life has been very chaotic, and that his mother had been completely overburdened by her many children. He remembers his family as a place where everyone had to fight for his own survival.
He had skin problems even when he was an infant. His earliest recollections revolve around the daily fights he had with his mother when he was a preschooler because he did not want to let her put ointment on him. But his yelling and screaming were useless: "With my mother, you didn't have a chance."
When his skin problems got particularly bad during puberty, he had several long inpatient admissions for cortisone treatments. He remembers his time in the hospital as having been very pleasant. He particularly recalled an older nurse whose care for him had been especially loving. He always preferred her to have her rub ointment on his skin.
He had a hard time graduating from school because he missed so much class time due to his illness. At present he is in an apprenticeship, but he is not sure whether he will be able to complete it because of his skin problems. He tells me also that he had a "special relationship" with his four-year-older sister. "That," he says, "is a story all its own."
Over the course of the dialogue, Mr. O. speaks ever more softly and incoherently, in fragmentary phrases, and I can feel his sadness and pensiveness increase. In spite of his physical size, he actually shrivels in the chair. In the countertransference, I have an image of a little injured boy who needs many kinds of care.
Overview of Attachment Dynamics
As the eighth and probably unwanted child, Mr. O.'s relationship with his mother is likely to have been very ambivalent right from the beginning. If one assumes that neurodermatitis has many causes, then one can at least speculate that an insecure attachment to the mother might be one aggravating co-factor. We may suspect that the mother experienced feelings of aggression and powerlessness toward the son who, as an infant, had resisted with such vehemence her daily attempts to at put ointment on his skin. Also, presumably, the child would have felt this care to his raw skin as very painful, and himself at the mercy of his mother's actions and emotions. Although caregiving may be an activity that fosters attachment to the mother, this type of care in the face of vehement protest is also a very aggressive interaction. Mr. O.'s mother represented the place where he could hope to receive care, relief, and protection for his painful skin. However, he also must have hated her for the pain she occasioned in her insensitive disregard of his wild protest. Such disregard for the child's needs in a situation that provokes fear leads to the experience of powerless rage and helplessness. This picture is typical of the disorganized attachment pattern.
I speculate that Mr. O.'s relationship to his mother was molded by a mixture of disorganized attachment with an underlying mixture of ambivalent and avoidant patterns. However, his ability to relate was evident in the fact that he felt emotional relief during his periods of inpatient treatment, and was apparently able to establish a positive relationship with an older nurse, allowing her to care for him without the aggressiveness that characterized his relationship with his mother. Perhaps his older sister may have served as his secure attachment figure. At the beginning of therapy, however, I was not at all clear what he meant by the "special relationship" with his sister.
It was remarkable that Mr. O.'s father did not appear at all in his entire narrative; when I inquired, the patient shrugged his shoulders and stated that his father "was always working." It remains unclear to me whether the father was present at all in the family. I suspect that the patient was so concerned with himself and his mother that in other respects he "disappeared" into the sibling group, and was not sufficiently seen as an individual by the father.
Because of the difficult, entangled, and aggressively loaded nature of Mr. O.'s attachment relationship with his mother, I expect that he will demand a great deal of closeness and security as well as caregiving and support from me in therapy. However, it will also be important to recognize his need for distance, given his background of avoidant attachment.
Therapy and Course
During the first phase of therapy Mr. O. expressed a great deal of concern about his relationship with his girlfriend. He feared that he might lose her; but in spite of his intense desire and need for closeness, he could only tolerate closeness for short periods of time.
Mr. O. came to therapy three times a week, a frequency that he chose himself. He looked forward to the sessions, always arrived early, and came through the door beaming. It soon became clear, however, that a fifty-minute session would be too long for him at first. He tested out sitting and lying down, and chose the lying position because he could relax better that way and didn't always have to look at me. In the classical setting the therapist sits behind the patient, but at Mr. O.'s request I sat next to him, because he felt that this did not threaten him or make him frightened. He could relax on the couch and look at me from time to time as needed. I was supposed to be with him in his feelings, but not (his great fear) "ambush him from behind": he recalled difficult encounters with his mother, who would "ambush" and catch him in the evening and then forcibly undress and bathe him before applying the ointment to his body, a procedure that seemed to him to last an eternity.
In the beginning there were times when he would have to get up after 20 minutes because he felt that he could no longer tolerate the tension inside him. Sometimes he would sit on the couch for while, and sometimes we were able to continue working like that. However, he sometimes had to leave before the end of the session. Mr. O. said he felt guilty because he was using "my expensive time" three times a week, but then leaving before the end of session, thereby disappointing me. In the context of his difficult attachment to his mother, we were able to talk about just how important it might be for him to decide for himself how much closeness or distance he needed. Over time, he was able to tolerate the physical tension he felt lying on the couch for longer periods.
During the phases of therapy when Mr. O. was looking at his enormous rage toward his mother, murderous fantasies began to appear of which he felt very ashamed. During this time, he experienced me as a persecutor who had forced him into "this stupid therapy," and who could determine everything, including date, time of session, beginning and end of session, vacations. Any attempt to address his aggression and disparagement of me in the transference was met with even more vehement verbal attacks.
Only much later did I learn that during this time, filled with aggressive tension, he occasionally rode his motorcycle on dangerous winding roads. At times he would pass other vehicles at blind spots on the road, fantasizing that only a "huge explosion" could free him. These quasi-suicidal actions may be understood as an expression of his enormous early experiences of aggression. At this same time, his skin symptoms became so acute that he considered checking into the clinic again. He expressed fear that I would not be able to stand him with his "burst and bloody skin" and that sooner or later I would send him away, just the way his girlfriend had threatened to leave him.
It took a fair amount of time before he was able to discuss closeness and distance with his girlfriend: although it was good that she was there, he could not tolerate the sort of intense closeness that she wanted with him. Their relationship relaxed somewhat when he dared to discuss this topic with her and asked to be permitted to set the terms of closeness. It was not easy to get his girlfriend to understand that his withdrawal or distancing did not mean that he rejected her; quite the contrary. He felt well taken care of by her, but he sometimes felt fear of dependency.
Later in the treatment Mr. O.'s relationship to his older sister became very important. I understood that she had represented his most stable attachment figure. However, this attachment relationship was not without ambivalence. He told me that when he was going through puberty his sister would climb into his bed at night. He looked forward to these nightly visits and awaited his sister longingly, because he found closeness and physical contact with her under the covers to be very pleasant. However, at the same time he felt sexually pressured by her: "If I wanted to be close to her, I had to pay a price."
Now we could understand how this "special relationship" had been activated in the transference to his girlfriend, and why he "exploded" at his girlfriend precisely in intimate situations.
Given his early rage, it required a high degree of sensitivity to follow and evaluate his desire for closeness and presence, as well as for distance and attachment avoidance. Often I did not know what to do; I felt that his demands for closeness and security were balancing on a tightrope with his aggression and his desire for distance, and that if the balance was disturbed rapid termination of therapy might easily result.
He continued to experience me as threatening when I tried too soon to talk with him about some aspects of his psychodynamics, and comments on the transference relationship triggered physical anxiety. He often reacted in sessions with skin symptoms (acute and extreme itchiness). I had a feeling that he was extremely frail, "thin skinned" in both senses of the word; I felt as if I were juggling a soap bubble, which a gust of wind or a touch at the wrong time would not lift into the air but, rather, cause to burst.
After a period of experiencing me as threatening and aggressively demanding in the transference, my office became a very reliable and structured "cave" for him. He paid attention to the setup and the pictures, as if the room itself were a predictable secure base that he could approach with less anxiety than he could me.
Sometimes he experienced anxious feelings of depersonalization, and could hardly speak. He felt that he was standing apart from himself, observing his lacerated and bleeding body, which was in the process of "dissolving, starting with the skin."
However, he eventually stabilized. Long vacations were crisis points. His skin broke out particularly badly just before a four-week separation. By then it was less difficult to talk to him about his fears of loss, and he said that he did not know how he would tolerate this "eternal vacation." In the second session to last before I left, he asked hesitantly whether perhaps he could take home with him during that time the picture that he always saw from the couch. It was so familiar to him, it belonged to this room and to me, and he would be able to orient himself by looking at it. I was very relieved by this idea, and gladly allowed him to take it that day, as he wanted to test it out at home and see if it worked. He was considerably calmer during the next (the last) session. The picture had found a good place in his apartment. He would "hold on to it" in my absence.
This transitional object allowed him to tolerate the vacation hiatus. The picture was a part of a place that he experienced as secure, a part of the space where I practiced, and a part that belonged to me, that he could keep with him. Apparently, he still needed a concrete picture in order to maintain a sense of security in my absence. In view of the avoidant aspects of his attachment, it is understandable that the room where I conduct therapy should be named and internalized as a place of safety more readily than the direct relationship to me, which activated the more ambivalent parts of his attachment.
After 2½ years, Mr. O. and his girlfriend separated. He was no longer willing to accept her desire for closeness at the level she demanded.
At first he had fantasies about taking a long trip. He had never gone on vacation alone. We had spent many hours on this fantasy, and on how the "expedition," which is what he called the planned trip, would unfold. He now felt much more secure, at least in his awareness that he could continue to separate from me, and "explore new continents."
Up until now, this idea had remained a fantasy, so I was very surprised when Mr. O. actually began to think concretely about his "expedition." He bought a vehicle that he converted into a sort of camper, whose living section could be uncoupled from the vehicle itself and left behind. This conversion occupied him intensely for weeks. At each session, he proudly reported each new bit of progress. His fantasies now concerned the properties that such a camper must have in order to be a stable, safe, and reliable "caregiver." He eventually coined the metaphor "mother-mobile" for this vehicle that he would take with him on his expedition as a secure base. He considered the fact that he could uncouple the "mother part" from the "mobile part," allowing him to explore the region independently, to be a great advantage, both practically and symbolically. He would be able to have his "mother station" with him on the trip as a secure base. At the same time, he could separate from it when he wanted to explore, in the full knowledge that he could seek out the "mother part" again as needed for such things as sleeping and cooking.
Many weeks after he had completed his house/vehicle, he decided, with considerable excitement, to plan a 3-month expedition. I wondered repeatedly to what extent these plans and fantasies represented a form of resistance that would allow him to avoid working through the transference in the here and now after he became more stable. Nevertheless, I did recognize his growing desire for exploration from the security of his base in therapy: in his fantasies at first, but then also concretely with the camper.
Finally Mr. O. set off on his expedition. It left me on tenterhooks, wondering whether everything would go well and if he would return safely. He noticed my anxiety at our last meeting, and he comforted me by saying that he would send me postcards from along the way to let me know that he was still alive and also where he happened to be.
In fact I did receive numerous postcards over the next 3 months from places on his itinerary. I was amazed that he was actually exploring new continents and seeming to make his fantasies come true. The trip was not without problems; his mother-mobile left him in the lurch several times and had to be repaired. Luckily, he was able to get help, and thanks to his own mechanical skills, he was able to do a number of repairs himself.
I would become uneasy when I didn't receive a postcard from him for a while, and then would be relieved when two would arrive at once. I followed his itinerary on a map, and so for those 3 months I was attached to him in my thoughts and emotions.
Three months after his departure, he stood beaming with his "mother-mobile" in front of my office. He arrived punctually at the time he had set before he left. He had a great many experiences to relate. I was happy for him and relieved that he had survived the trip so well.
From that time forward, he entered a phase of separation from me and from his therapy. He was able to think about terminating without troublesome fears or new skin outbreaks.
Upon termination he gave me a picture that he had brought back from his trip. He thought that I should hang it in my office so that I could remember him in his absence--the same way that the picture from my office had helped him to endure separation during my first long vacation.
Concluding Remarks and Follow-Up
Mr. O.'s therapy, which lasted 3½ years, at three and sometimes four sessions a week, had led to marked ego stabilization. Building on attachment dynamics, we were able to work through his disorganized attachment relationship to his mother in particular and his difficult relationship with his sister.
At times, I was almost certainly both mother and father to him in the transference. Particularly during the last phase of therapy, when he was planning his trip, it became clear that he wanted to talk to me "man to man" about the expedition. With a foundation of growing attachment security, it became possible for him to realize his desire for individuation and exploration at the concrete as well as the symbolic level. His invention of the mother-mobile allowed him to go long distances from his secure place in therapy for a long period of time, because he was able to take his secure base (in the form of the mother-part) with him.
Although his neurodermatitis was not cured, he had no more acute outbreaks. This in and of itself was a great relief to him. By the end of treatment, he could hold his skin "at bay" with ointments; he had no further need of cortisone cream.
I received a wedding announcement from Mr. O. 2 years later, and a short letter from which I concluded that he was making his way in life. He had established himself professionally in a new independent business and according to his reports was being successful.
© The Guilford Press 2002
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