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by Karl Heinz Brisch
Guilford Press, 1999
Review by Roy Sugarman, Ph.D. on Aug 12th 2004

Treating Attachment Disorders

If you have been around long enough, you will remember the black and white films produced by Bowlby, who began looking at children left behind in hospital wards during the treatment of their illness.

Then again Suomi has looked at the same thing in his monkeys off the coast of America, and the various studies around these two names date back to the times when the times were a'changin.

 Namely, Bowlby was one of the first to break away from then already traditional views of drive and object relations, and investments of drive and energy by catharsis, and begin to use what Family Therapy and related doctrines were thinking about, namely general systems theory in his thinking, angering everyone around him in England.  Nevertheless his science was even then regarded as too important to ostracize, and so ideas about separation and attachment grew, and continue to grow today.

Psychoanalytic views would more or less hold that a child is initially unaware of its separate status vis-à-vis the primary love object, namely the 'sensitive' mum usually, but begins to realise this separation when the period of infantile narcissism is shattered by the tardiness of the magical force that changes the diapers: the Ego is born, tested in early years by the "Strange Situation" role plays. Sensitivity in this sense is somewhat like Kohut's 'empathy', but with an action figure present, more external a process.

Bowlby (and Ainsworth and others) however began to show that this was a two-way street, and the quality and the quantity of the interaction bilaterally would define the extent to which the child adapted to separation, a necessary entity to allow both the freedom to interact with the world out there, and the need to feel secure while doing so.  This pushme-pullyou demon requires some balancing of appropriateness on mum's part, lots of parental judgment guiding the process.  As the child goes on to the adult world, this is going to influence all attachment processes, and the jargon goes, if not resolved and dealt with in relationships, old habits will get in the way and cause disruption and attributions of personality disorder for instance might result from rigid management of relationships.  So, attachment issues carry on through the adult lifetime, and may have to be dealt with clinically.  Transgenerational studies however have shown less predictability than within generation, longitudinal studies, and one wonders what the Germans would have done without Grossmann and colleagues to fill their research volumes?

A great deal then depends on who is out there for the child and then adult to be cushioning and sensitive as secondary and tertiary mum figures.  Of course, the psychotherapeutic relationship is just one hotbed for the old libidinal drives, and attachment needs work in these settings in the analysis of the transference, and the management of the counter-transference.

This is Brisch's arena.  Looking at his case studies, which illustrate just about everything, he finds the problem with attachment in many spheres of human clinical pathology. Drawing on his position as a child and adolescent psychiatrist and psychotherapist, an adult psychiatrist and neurologist (is this giving away his age, or do they still do dual registrations of this in Germany?), he is the head of the Department of Paediatric Psychosomatic Medicine and Psychotherapy at the Ludwig-Maximilians-University of Munich, he deals with all sorts of presenting problems.

There is of course a physiology to go along with this, and he discusses it around pages 55-57 in essence.  No real reference is made to the works of Teicher, Glaser and others, in the effects of abuse and neglect on the brain, since Brisch is after subtler stuff.  Nevertheless he does make it clear there is research into the endocrine and neurotransmission systems of the body as a whole, hence his interests and academic position in psychosomatic medicine.

He goes on to flesh out his typology, with classifications such as 'no signs of attachment behavior', to 'undifferentiated attachment behavior', 'exaggerated attachment behavior', 'inhibited attachment behavior', 'aggressive attachment behavior', 'attachment behavior with role reversal', and finally psychosomatic symptoms.  This second last lot is a bit hard to distinguish from normal firm attachment, but is less reciprocal, and so is linear, not second order cybernetic and self-regulating, and hence it is regarded as pathological from a general systems point of view.

General systems-based theories of mental illness were often criticized for the perceived neglect of the unconscious in outlining their putative theories of the origins of mental illness.  As with the early criticisms of Bowlby by the Kleinians, many of the near-sacred underpinnings of psychodynamic thought were abandoned in the new approaches to such phenomena as attachment, as described here by Brisch.  In our new era, with the focus on the need for evidence based practice in psychology and medicine, definitions of psychopathology based on theories of the unconscious fall foul of one of the salient demands of empirical science: the concept of the 'unconscious' remains an untestable hypothesis, one which is not subject to empirical investigation and therefore there is the capacity to potentially be refuted by such an investigation. Brisch is clearly drawing on effectiveness to tell us if the therapy works, i.e. there is strong external validity but weak internal validity in such a model., when compared to laboratory experiments which attempt to investigate the efficacy of such an approach.  Efficacy research is the most scientifically rigorous, in that it relies on randomised clinical trials with a 'double-blind approach', not selected case studies, as Brisch has done here. In offering us proof of the value of his methodology, there are more than just the 'unique' aspects of his therapy acting on the systems in which he is intervening.  The efficacy approach thus is said to possess strong internal validity, as apposed to the external validity provide by Brisch's approach, which generalizes better to therapy as it is normally practiced outside of the laboratory, providing the ecological representativeness alleged by Brisch's choice of a wide variety of clients for his illustrations.

Pages 87-237 are then engaged in just such an approach, demonstrating the presumed effectiveness but not the efficacy of his model and approach, as well as his knowledge of the full spectrum of attachment concerns and disorders in the clinical setting.  In this setting, Brisch believes, and advances the opinion that attachment theory can be applied to all symptoms, diagnoses and therapeutic approaches, (but not to every mental illness necessarily) and is a fundamental motivation, expressing itself across the childhood, in adolescence, in adulthood and old age, its never too late, as one of his case studies shows.

Outcomes?  Well he does say in closing that it may be possible to alter a patient's strategy by psychotherapy, in one study at least, in 1995.  He notes it lies in the hands of empiricists to determine if the theory, as applied clinically, has outcomes.

It's an interesting work, written well enough to be read casually, and it does not offend those without such devout beliefs and theories. This is a scholarly man, writing of a naturalistic study, pointing out the efficacy of not neglecting attachment, given the wide body of clinical evidence of its presentation in psychiatric settings, and of the value in considering it, if not always addressing it.  It's eminently seductive, and like Piaget, when we observe our own children and patients, we see these things, even if the evidence base is not clear.



© 2004 Roy Sugarman


Roy Sugarman, PhD, Clinical Director: Clinical Therapies Programme, Principal Psychologist: South West Sydney Area Health Service, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia.

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