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