L’interprétation à travers le prisme de la psychothérapie de couple fondée sur l’attachement

Interpretation viewed through the lens of attachment informed couple psychotherapy^[*]

Christopher Clulow ^[**]

Introduction

What makes a difference in therapy? The most likely reply from psychoanalysis is interpreting the unconscious as it surfaces in the transference. This answer looks straightforward until you realise that the nature of interpretation, what constitutes the unconscious, and the various sites of transference are not fixtures but vary according to time and context. Whereas President Clinton famously accounted for change with the phrase “it’s the economy, stupid”, we psychotherapists might answer by substituting the word “relationship” for “economy”. It was, after all,

Donald Winnicott who remarked «there is no such thing as an infant»(Winnicott, 1964, p.88), meaning, of course, that infants can only be understood in the context of the relationships that surround them. He focused attention on these relationships as the bedrock on which human development (and we might add, much else) depends.

Relationships form an essential part of the environment of adults as well as children, so we can apply Winnicott’s saying to grown-ups too. It’s relationships that matter, so relationships should form the focus of our attention. The fortunes of couple and family relationships are affected by the balance of the demands made on them and the support they receive. Culture, climate, pandemics, wars, work, material circumstance, education – all these and other factors have an impact on relationships, for better or worse. But relationships also mediate between and can moderate the impact of events on family members. They comprise part of the environmental tapestry affecting the health and well-being of individuals, and influence how the entrances and exits to family life are navigated.

Affective connection and psychotherapy

The process of connecting begins at the very start of life. The sexual connection between sperm and egg sets in train a complex process of cell generation and division that will eventually, all being well, result in the birth of a baby. It is tempting to think of this as a purely physiological process and to discount accompanying nurturing factors. But that would be to fall into the Descartian error of separating mind from body. From the outset a mother’s womb forms the environment that interacts with her baby, an environment that will be affected by her lifestyle and relationships, transmitting nutrients and toxins through the umbilicus that connects them. Following birth, the environment of the womb is replaced by relationships with parents and others who are entrusted with their care. We have come to learn how vital these relationships are, not only for developing social, motor, emotional and intellectual skills, but also for developing the physiology of brains. We also know that infants are not passive players in this process: they actively influence the responses they receive from their parents.

Neuroscience is a complex and developing field, and even specialists are cautious about the assertions they make. The best that someone like me can do is weave a story around what I have come to understand from my limited exposure to this new and rapidly growing body of knowledge. It seems to me that neuroscience highlights the importance of connectivity for every dimension of development. One connection of particular significance for therapists is that between feeling and thought – between affect and cognition. Put simply, our range of therapeutic modalities revolves around just three assertions: how you think affects how you feel, how you feel affects how you think, and how you think and feel affects how you behave (under behaviour I include actions directed outwards towards others and symptoms resulting from internalising distress). Cognition, affect and behaviour: these define the focus of therapeutic action. Therapies differ according to which is paid the greater attention.

I am persuaded that emotions are the drivers that define whether and what connections are made within and between people, and it is by coming to our senses – recognising and regulating emotional experience triggered by bodily states and external stimuli – that we develop the capacity (in biological terms, the pre-frontal cortex) that allows us to think. While cognition – how we think – is clearly vital in affecting our responses, that very capacity rests on our success, or otherwise, of recognising and regulating our emotions. Affect regulation and security in relationships are linked in a circular manner, each being cause and consequence of the other: attachment follows from the experience of emotions being regulated/contained within a relationship, and a central function of attachment is to do just that. Emotions form the mood music of life, oscillating in volume according to stimulus, and generating themes that can be as soothing as a lullaby or intrusive as an ear worm.

There has been much debate about how we might differentiate between affect, emotion, and feeling. The terms are often used interchangeably, and there is no commonly agreed set of criteria for making distinctions between them. Neurobiologists often refer to affect and emotion as the background drivers common to all mammals, automatically regulating internal bodily states and providing the impetus to explore environmental opportunities and defend against territorial threats. Feelings are more subjectively defined, and attributed to emotional states of which a person is conscious – for example, feeling hungry, full, happy or sad.

Affect was the term used by John Bowlby, the father of attachment theory, to describe emotions, sometimes consciously recognised as feelings, which are experienced towards specific people who have significance for them. He called these connections “affectional bonds” (Bowlby, 1979). There is some irony in that while Bowlby recognised behaviour, cognition and emotion as the cornerstones of development, his attention focused primarily on behaviour (the set goal of attachment being to attain proximity to the caregiver) and cognition (how internal working models develop, a term derived from the behavioural psychologist Craik). It was left to Alan Sroufe and others to focus on the affect associated with attachment, and to redefine the goal of attachment behaviour as achieving felt security (Sroufe & Waters, 1977).

Bowlby’s term ‘affectional bonds’ appeals to me because of its relevance to psychotherapeutic practice. Problems encountered in forming, maintaining and breaking affectional bonds frequently mobilise couples to seek help. Regulating disturbances of affect in relationships between partners and between couples and therapists lies at the heart of every therapeutic process, whatever modality is deployed.

Triangular dimensions of interpretation

Where does interpretation fit into this process and the practice of attachmentinformed therapy – note that I adopt the language used by Jeremy Holmes and Arietta Slade (2018) to avoid implying this is a new therapeutic model. Insofar as attachment theory addresses unconscious processes it fits within the canon of psychoanalysis. It focuses on the role relationships play in neurological, behavioural and affective development in the first 18 months or so of life, by which time attachment patterns are usually firmly defined, and an internal world of object relationships established. Early relationship experiences are committed to procedural memory, which, unlike autobiographical memory, is not accessible to conscious awareness but stores important information about what to expect from, and how to adapt to, different environments. These early months are a time that precedes language: that capacity to symbolize and communicate about experience through words. What implications might this psychoanalytic theory of early development have for psychoanalysis, “the talking cure”?

The psychoanalytic answer to this question is to focus on the transference relationship, a conduit through which unconscious information is conveyed from patient to analyst by eliciting an affective response in the analyst that is key to understanding the patient’s predicament. When I started work at Tavistock Relationships I was much influenced by Henry Ezriel’s paper, which converted the

Freudian distinction between defence and anxiety into a relational format: the ‘required relationship’ being a way of engaging with others while remaining protected from anxiety associated with “avoided relationships” (Ezriel, 1951). A former colleague of mine, Graham Davies, argued that you could always spot when a relationship was “required” by the anomalies that crept into the experience (Davis & O’Farrell, 1976). To be told about a harrowing incident in a calm and smiling manner can elicit horror in the listener, signalling the avoidance of something felt to be catastrophic. In the Adult Department of the Tavistock Clinic, David Malan developed a means of assessing psychotherapy by triangulating the transference experience with accounts of past and current relationships (Malan, 1979). If there was a degree of congruence between the three there would be grounds for making an interpretation.

Triangulation is a word often associated with the pursuit of objectivity, certainly in the world of research. And there is something objectifying about Malan’s formulation, which sets the observer apart from the person being observed. It brought to my mind associations with navigational history, where ships out of sight of land would rely first on sextons, and then, more reliably, on the chronometer, to triangulate readings that would establish their location, so they were not at the mercy of the elements. What do we rely upon when we find ourselves at sea in our personal and professional lives? Will internal or external landscapes determine the courses we set? And what shall we use to triangulate the influence they have on us? Without a capacity to consider both landscapes and take up a position in relation to each of them – in other words to have agency – we are at the mercy of unmediated forces. In couple psychotherapy each partner forms a key part of the relational landscape for the other, and, as Mary Morgan has underlined, the aim of any couple interpretation is to enable partners to develop a ‘third position’ in thinking and feeling about their experience (Morgan, 2019).

The distinction between “pretend” and “psychic equivalence” modes of relating is relevant in this context. Each mode of functioning is concerned with managing the boundary between inner and outer worlds, and describes processes that operate when there is no, or very limited, capacity to distinguish between them. Pretend functioning denotes a retreat from engaging with the external world into an internal world of thoughts and feelings that are segregated from external reality. Psychic equivalence functioning reflects a mindset in which internal realities are especially susceptible to being defined by external realities. Each mode precedes the capacity to “mentalize”, to know about and draw distinctions between different intentional and emotional states in oneself and others, and to reflect upon connections between them (Fonagy & al., 2002). Mentalization is triangulation in action, holding a third position, or, in the language of attachment, metacognition, or reflective function.

Earlier this year saw the death of Mary Main, a developmental psychologist whose name is primarily associated with capturing disorganised attachment in the behaviour of young children and devising the Adult Attachment Interview. In assessing attachment security in adults, she moved from the observational approach of the Strange Situation Procedure used with infants to what she famously described as the ‘level of representation’ (Main & al., 1985). Raters of attachment security look not at the content of what interviewees say when describing their experiences of growing up, however wonderful or awful that might have been, but at how they speak, or fail to speak about them. A triangular capacity is at the heart of the discourse associated with attachment security, as it is with any good conversation. Interviewees who are capable, on the one hand, of co-operating with the interviewer by responding to questions with answers that are relevant and bounded, and, on the other, of having a relationship with themselves by reflecting on the answers they give, are deemed to be secure in terms of their state of mind. The story they have to tell is coherent; they have found a place to stand in relation to themselves and others and so have leverage, a sense of personal agency.

Attachment, research and couple psychotherapy

I remember how delighted I and other colleagues at Tavistock Relationships were to discover this research instrument, persuading two of us to undergo the rater training. At last we had something that ‘surprised the unconscious’, something that might be used to capture unconscious contracts between couples. We played with designing an attachment interview addressed to the couple as a unit, a psychometric project that unfortunately failed to reach fruition (Fisher & Crandell, 2001), although a subsequent initiative rooted in Kleinian concepts was more successful (Lanman & al., 2003). Other attachment researchers have succeeded in their approach to designing measures of attachment security in couples, whether through using questionnaires (eg Fraley & al., 2011), observing behaviour (eg Crowell & al., 2002) or analysing discourse (eg Alexandrov & al., 2005), but the AAI paved the way for research in developmental psychology.

Contrary to clinical prejudice, research does have things of value to offer therapists. For example, rating the security of relationships between infants and parents through the Strange Situation Procedure focuses on how infants behave when they are reunited with their parents after a brief separation. Reunions result in behaviour that shines a light on defences, inviting us to consider in a clinical context not only how people deal with breaks in therapy, but also with the process of restarting after a break – even if the break has only occurred because of the gap between sessions. The AAI similarly challenges adults: in recounting attachment histories it elicits from interviewees how they represent their developmental history in the context of a potentially threatening situation (threatening because it probes affective experiences). Of course, the risk in either case is that subjects become objectified by being assigned to predefined categories. While researchers may need to categorise in order to measure, therapists don’t have this constraint and can be more flexible. We are more likely to be drawn to the inquisitive dimension of the interview, to the significance of its subcategories, and to fluctuating states of mind revealed by how people speak about their experiences than to assigning them to a category.

By and large, attachment informed psychotherapy is not founded on questionnaire assessment, although it does emphasise the value of observation, including observing oneself as well as others. Bowlby’s conception of the therapeutic process was very much about providing a secure base from which individuals might explore themselves and their relationships, an analogous process to his depiction of young children feeling safe enough to circle increasingly further away from the physical base provided by their parents to explore the world, confident of their enduring presence, support, and encouragement. Insofar as interpretation featured for Bowlby, its value was less in explaining than in encouraging exploration, a process in which he put the patient firmly in the driving seat: “You know, you tell me,” was his maxim (Bowlby, 1988, p.151). His father was an eminent orthopaedic surgeon, and Bowlby created an analogy between surgeons creating conditions in which broken bones might mend and therapists creating conditions in which fractured selves might mend. Both procedures need a protective envelope to be carried out safely.

It doesn’t need neuroscientists to tell us that unless we feel safe we cannot explore, although that is what they do. Many couples come to therapy because they don’t feel safe enough in their relationships to have the conversations that matter. And we therapists may unconsciously block such conversations when we feel unsafe and inhibited from attending to disturbing experiences. The consulting room’s primary function is to provide a safe place – what Bowlby described as a “safe haven” – in order to make these conversations possible. I have learned to have great respect for people’s defences. They are strategies – ‘required relationships’ in Ezriel’s terms – that were initiated during infancy and have developed over time to manage anxiety, so they have value and are not to be discarded lightly. Couples often have similar or complementary defensive strategies which constitute the shared defensive structure of their relationship. Going it alone, competitive fighting, and coercive caregiving are just some of the ways relationships can be organised to defend against vulnerability. As with all defences, there will be the anomaly that invites the opposite of what is intended – the chink, if you like, that lets the light in. That chink brings couples to therapy.

When we consider disorganised attachment as approach – avoidance conflict, that is, conflict arising from situations where the person we wish to turn to for protection also represents the threat from which we need protection, the relevance to couple relationships is immediately apparent. If one partner’s emotional security depends on “going it alone”, and the other’s on “going it together”, any threat is likely to trigger the pursuer-pursued behaviour so commonly encountered in couple therapy. The positive feedback loop resulting from combining dismissing and preoccupied responses to anxiety, infused with disorganised attachment, can be sufficient to trigger interpersonal violence (Clulow, 2007). Conflict over whether to approach or avoid a partner when feeling upset by their behaviour lies at the heart of disorganised attachment. Such conflict can trigger responses associated with dormant, unresolved, histories of loss and abuse.

Two dimensions of interpretation

What relevance might this have for interpretative technique? I was interested by Heinz Kohut’s distinction between leading and trailing edge interpretations (Miller, 1985). In order to get a therapy off the ground, so to speak, he suggested that the lift provided by acknowledging the value of a defensive structure, and how it might be supporting a belief that this was the way to achieve a desired outcome, or, at least, to avoid a catastrophe, could contribute to making therapy a safe place. In contrast, trailing edge interpretations were essentially retrospective, revisiting and integrating previously split off developmental experiences which accounted for how and why defensive strategies had come into being.

Recently I illustrated how this might translate into practice (Clulow, 2017):

A wife describes how she scans her husband’s face to know what he’s thinking and feeling, but is frustrated by the impassive mask he presents to her. They have been to visit a house she’s interested in them buying as the family home, and she doesn’t know what he thinks about it. So she pushes for a response. When she pushes, he withdraws, sometimes angrily, creating the all-too-familiar experience for her of rejection, so she protests. His dilemma is that he often doesn’t know how he feels, and fears her becoming upset with him if he expresses a view that is contrary to her own. He represents relationships in his family of upbringing as being inverted, with him looking after a narcissistically preoccupied mother left by his father to fend for herself. She represents her family history primarily in terms of abandonment, where those who were responsible for her left her to fend for herself. He seeks to know what she’s thinking before committing himself to expressing a view, so looks to his wife for implicit guidance. She searches for a reaction from him so she does not feel on her own with her experience. His impassiveness drives her crazy; her craziness drives him away. He defends himself against the onslaught of her feelings by expressing concern about her state of mind and, in extremis, wonders if she needs psychiatric help, as his mother had done. She then confirms his fear by exploding at him.

The trailing edge approach to Interpreting this situation might be to focus on the transference between the couple, and to link the way the husband relates to his wife with the way he related to his mother, evoking aspects of this overwhelming dynamic in his transference to her. The conflict from his history might be represented as feeling caught between complying with what she wants, or giving vent to his anger about being eclipsed in his own right (anger that he might be fuelling in his wife through projection). Likewise, one might interpret how his impassiveness revives for his wife memories of abandoning parents, about which she continues to protest. A joint interpretation might home in on how they both contribute to creating a system that highlights the dilemma for which they are seeking help, one in which neither feels cared for as people in their own right. Or, focusing on the couple’s relationship with the therapist, the interpretation might explore whether in searching for a home for their relationship the husband was complying with therapy to counter a threat of intrusion or control, and the wife was feeling frustrated by the impassive mask of a therapist who was refusing to support her.

In contrast, a leading-edge interpretation might emphasise how each partner was feeling anxious and had turned to tried and tested ways of managing that anxiety. Their different approaches to this (not them as people) might be identified as a cause of their problems. The interpretation might stress how they both were wanting to establish a sense of emotional security within themselves and their relationship. This, then, becomes an objective that can be represented as something for which they are both striving, a positive experience in which they can feel together as a couple, but one about which there is understandable anxiety. The interpretation might be extended to incorporate how they wish for, but share similar fears about, developing intimacy in their relationship, and have become divided over this, he relying upon her to represent his wish for intimacy and she on him for providing the safeguard of distance.

Leading-edge interpretations are not removed from trailing-edge interpretations: acknowledging that emotional security has been fragile in the past provides an important context for what they are trying to achieve in the future. However, by focusing on future intent, it may be that they help establish a secure base for the couple in their relationship and in their therapy. They do so by reframing behaviour, valuing rather than challenging defences, and facilitating the process of the therapist building an alliance – that key ingredient that has generally been associated with good outcomes – with each of the partners. Working on the leading edge opens the way for introducing trailing edge interpretations that evoke and challenge a couple’s separate and shared assumptions about each other and their therapist, highlighting the impact of their existing internal working models on themselves and each other, and enabling their unconscious assumptions to be revised and updated. In these circumstances, they provide a prequel to reflective thinking.

Mirroring, mutuality and love

Reflective thinking results from ‘good enough’ relationship experiences, and you will notice that I am here returning to Winnicott’s language. I have been much taken by what he and others have written about the significance of mirroring in child development. Not only do mothers hold their infants in bodily terms but also in affective terms, shaping their existential sense of self. Applying this to the psychotherapeutic process he wrote:

«This glimpse of the baby’s and child’s seeing the self in the mother’s face, and afterwards in a mirror, gives a way of looking at analysis and the psychotherapeutic task. Psychotherapy is not about making clever and apt interpretations; by and large it is a long term giving back of what a patient brings. It is a complex derivative of the face that reflects what is there to be seen» (Winnicott, 1967, p.114)

From Winnicott’s perspective, what the mother does, in the best of all worlds, is to read accurately the cues of her baby and to respond in ways that are in tune with the baby’s internal state, while drawing a distinction between what belongs to her and what belongs to her baby. Her success or otherwise in accurately reading and appropriately bounding that experience has been associated with different patterns of attachment. Secure attachment is associated with attuned and appropriately differentiated responses; insecure dismissing attachment with differentiated responses that lack attunement; insecure preoccupied attachment with attuned but undifferentiated responses.

How might this apply to couple relationships? Let me illustrate a fragment of interaction from a couple I have called Tamsin and Tom (Clulow, 2014): Tamsin described an ongoing problem she had with her mother, a woman she found it difficult to connect with. She said she would tell her mother what was going on in her life but felt that she either didn’t listen or tended to be critical. She got annoyed when she found that her mother would subsequently tell her friends things she had told her, as if to boast about her, but never seemed to react much to her, or to offer her positive affirmation … Listening to this, Tom waded in saying that Tamsin’s mother was indeed a very self-preoccupied woman, and that Tamsin needed to protect herself from her and not get caught up in her agenda. While he appreciated the childcare support she sometimes offered them, he felt she could sometimes stir things up between him and Tamsin when she handled their child in ways they didn’t like. His response prompted Tamsin to become tearful. I asked what her tears meant, puzzled because Tom seemed to be echoing some of her sentiments. She said she didn’t like her husband wading in like this because he painted a picture of her relationship with her mother as being worse than it was. She said Tom didn’t recognise that she still needed something from her mother, and her tears were of frustration with him for not understanding this. She knew she was frustrated by her mother, and having become a mother herself was more aware of what she longed for and had missed from her own mother than ever. But she needed to protect her from Tom’s criticism.

What seemed to have gone wrong in this exchange was that while Tom had picked up on and responded in an attuned way to Tamsin’s frustration with her mother, he had added some of his own frustration with parent figures (that is, his response had not been adequately differentiated), so Tamsin was left with an experience of something alien or incomplete being attributed to her that she needed to resist. In attachment terms she was describing a relationship with her mother that was on the preoccupied side of secure. She was describing an ambivalent, involved relationship that continued to make her angry, and there was some indication of role reversal and projection in her wish to protect her mother from the anger and criticism that she attributed to Tom but also felt in herself. It seemed that Tom could then become either the non-understanding or the appropriating maternal object against whose intrusions Tamsin needed, through her tears, to protest and protect herself.

Therapists can intervene to manage the boundary that governs effective mirroring between partners, encouraging an affective tone to emerge from generalised statements about experience, or indicating when a response to a partner’s distress might appropriate that distress through the boundary between their experiences being breached. For couple therapists, the task is to enable the couple, rather than the therapy, to do this – something that can be challenging even in the best of times, especially when the trauma of betrayal has made it hard for one partner to overcome the mistrust of a mate whom had previously been trusted. Technique implies the freedom to think about the behaviour of others, and can obscure how frequently therapists as well as couples can feel at sea, and how tempting it can be in these circumstances to reach for an interpretation as a defence against not knowing. We know that borderline structures and disorganised states of mind can particularly undermine the capacity to think and feel, and how intrusive interpretations can be in such circumstances. This knowledge cautions us to be curious rather than knowing in how we intervene.

I remember learning from a couple where music provided the means of connection between a father and son, sometimes to the exclusion of the mother. I had my theories, and they had theirs, and the therapy was very much an interplay between us, from which I gained a lot. The experience prompted me to think about therapy as jazz improvisation. This is what I wrote:

«There is an elemental demand for connection in the call-response nature of much jazz, especially the gospel tradition, which was and remains rooted in religion. It is an inclusive form of conversation, involving listening and responding both to oneself and others; it is an unscripted, impromptu means of connecting affectively both inwardly and outwardly. Musical expression can reach the heights of transcendent joy and the depths of angry grief. An analogous image from developmental psychology would be the interactive callresponse sequence between a mother and her infant that repeats with different levels of intensity to build and moderate excitement and mutual enjoyment. Similar patterns are evident in the way couples interact, the statement of one partner inviting the other to respond. The absence of a response, a slow quiet response to an animated invitation, or a rapid emphatic response to a carefully muted invitation, can be frustrating when it signals partners failing to find a mutually workable tempo in their communication.

One of the distinguishing features of jazz is the emphasis it places on improvisation. It allows musicians to become composers in the very act of performance. Theirs is not the task of interpreting through tempo and expressiveness notes that have been scored by others, but to create notation and rhythm for themselves» (Clulow, 2020, p.79-80)

Conclusion: interpretation as an act of love

Translating this into research-based, academic language, I found love defined in the Handbook of Emotions as a transitory experience generated by micro-moments of positive resonance between people. Safety and eye contact were the preconditions for such an experience, which synchronised affective, behavioural and biological responses. «At its core, wrote the authors, “love is a pleasant and momentary experience of connection with another person (or persons)» (Frederickson, 2016 ,

p.848). From this perspective we might say that, providing it results in a sense of connection, interpretation is love in action. Philip Larkin’s 1956 poem, “An Arundel Tomb”, describes a stone mason’s depiction of an earl and countess lying in state together (Larkin, 1964). All the formalities of dress have been observed in the sculpture until the eye alights on a small but significant detail: one of the earl’s hands is withdrawn from his gauntlet and is holding the hand of his countess. Whether this point of connection expresses the sentiment of the couple, the stone mason, or the onlooker may never be clear. But we might ponder on Larkin’s concluding words:

“what will survive of us is love”.

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Interpretation viewed through the lens of attachment informed couple psychotherapy
Christopher Clulow

https://doi.org/10.69093/AIPCF.2024.31.05

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY).

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^[*] Consultant Couple Psychoanalytic Psychotherapist and Senior Fellow at Tavistock Relationships, London; member of the editorial board for the journal Couple and Family Psychoanalysis. christopher.clulow@outlook.com

^[**] This paper was given on June 9^th 2023 as part of the Lectures from the Tavistock Relationships Model series and was subsequently published in Attachment. New Directions in Psychotherapy and Relational Psychoanalysis, 17 (2): 173-184, December 2023. It is reprinted with the kind permission of Karnac Books.