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DIAGNOSIS OF ATTACHMENT BEHAVIOR AS AN INDICATION OF CHANGE IN COGNITIVE PSYCHOTHERAPY


Giacomo Mereu M.D.
Centro per la prevenzione delle fobie scolari, onlus.Cagliari- Italy

Methods for the evaluation of patterns of attachment now available offer therapists the tools with which to assess this aspect of the personality during a person's entire lifespan. Longitudinal studies performed in this field have shown that patterns of attachment, once they have become structured at the age of one year, as assessed by means of the strange situation, tend to remain unchanged up to and beyond the age of six when the family situation remains stable, and then vary with the occurrence of a specific "life event" (1). The Adult Attachment Interview (A.A.I.)(2) is the method used to evaluate the "state of mind" of an adult vis a vis his or her history of attachment, which in 80% of cases is correlated with the behavior of attachment as assessed in the children of these adults by means of the strange situation at the age of one year (3). These methods are used to study the transgenerational transmission of patterns of attachment and therefore offer important suggestions as concerns prevention.
Such methods were used in the course of this work to monitor the effect of cognitive psychotherapy in an attempt to modify the state of mind of a woman of 34 years of age in relation to her history of attachment, and consequently the transgenerational transmission of the pattern of attachment to her child.
Psychotherapy, which began in 1986, was interrupted for the first time for a period of two years after eighteen months of treatment. Therapy was resumed in 1990 and was again interrupted halfway through the woman's pregnancy. Therapy resumed again following the birth of the child and is still in progress.
Case History
The patient, whom I shall call Ms Z from now on, began psychotherapy at the age of 34. Unmarried, she had been living alone for over a year. Her father died when she was three. From the age of 3 to 5, she lived with her maternal aunt and uncle. At the age of 5 she was placed in a boarding school, where she remained up to the age of 11. She is the youngest of six children. Her eldest sister, who is twenty years older than she, took over the management of the family following the death of

the father. The mother, now in her eighties, is described by her daughter as always being ill.
Z works as a civil servant. She began therapy because of a state of social anxiety and various somatizations. In terms of the cognitive theory of the personality, she revealed a mixed organization of the personality with a depressive nucleus and traces of "psychogenic eating disorders" (4).
At the beginning, treatment concentrated on the anxiety emerging from Z's interactions with others. To exemplify, some clinical vignettes are given below:
"... I realize that I get a sense of oppression in the chest, I feel like I'm suffocating and I have a lump in my throat and stomach when I feel oppressed by somebody like my uncle, my mother, or the school principal."
"... I have to be sincere towards other people (...) but I can't show my disappointment in them because they might get offended, and so I feel like I'm suffocating, I get this sense of oppression in the chest and a lump in my throat because I can't say what I really think."
"... once I told a friend of mine some things I didn't like about her, I was pretty caustic. I didn't feel anxiety, but she left in a huff and now she doesn't speak to me any more and I'm sorry about that. I see that all my relations with other people are a failure."
"... the others ride roughshod over me, they don't understand me and I've never had any help from them when I needed it."
She describes her situation as follows:
"... I always feel bad. I can't remember a day when I've been able to said: "I really feel good today"; usually I feel sick physically. If I get over a stomach ache, I get a headache and so on and so forth. For about four years I've been going from one sickness to another. Up to then, I didn't even have a doctor..."
Later, on thinking back, she concluded that her poor health had begun after the breaking up of a sentimental relationship that had lasted for ten years. Analysis of her main affective relationships led to the overcoming of the "resistance" that arose in her relation of transference with the analyst. "The people I want don't give a shit about me! I don't like the people who want me. Nobody wants me."
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Her ideal self emerges:
"... I don't want to continue this therapy any more because the last time I didn't like the way I acted. I found myself speaking so impulsively - what a horror show! I felt so vulgar, so shook up, it bothers me the way I was acting, like the kind of people I don't like."
"... I'd like to be better-mannered and not shout, but be nonchalant and act with the most orderly spontaneity, which is the real spontaneity, the most authentic there can be. This is a contradiction, but not really, because there's no real spontaneity at any level. I'd like to reach this planned spontaneity, with good taste and style. There is no such thing as absolute spontaneity; everybody pretends to some degree, so it's better to pretend with style, in the sense that vulgar spontaneity is mediocre, it's false spontaneity.
If I find myself acting spontaneously and I start squawking, which is a mediocre way to act, I feel horrible and I don't like the image I project."
"... I'm pessimistic about others, and about myself with others, and that's why I've come to terms with loneliness. To be by myself is easier than being with others."
Only after six months from the beginning of therapy did Z mention for the first time her brother, who committed suicide. She reports that she sometimes feels guilty towards her brother.
"For a long time I was sure I would commit suicide too. I had set the time, when I was the same age he was - thirty-three. I thought I would commit suicide two years ago."
The subject of loneliness emerges:
"... I get angry and sad about the loneliness there is in relations with others. Loneliness is the sense of the futility of talking to others and not communicating with them. Not being able to communicate is worse than being alone, and that's why it's better to be alone."
"... solitude is my choice, as if it were a way to spite others. It's like a conquest, a kind of pleasure in doing without others."
The strategy of John Bowlby, as he described it the quotation below, was then applied.
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"In terms of the present theory much of the work of treating an emotionally disturbed person can be regarded as consisting, first, of detecting the existence of influential models of which the patient may be partially or completely unaware, and, second, of inviting the patient to examine the models disclosed and to consider whether they continue to be valid. In pursuing this strategy an analyst finds that how the patient perceived him (the analyst), and what forecasts the patient makes about his likely behaviour, are particularly valuable in revealing the nature of the working models that exert a dominant influence in the patient's life. Because certain of these perceptions and forecasts appear to the analyst so clearly to be based on a patient's preconceptions about him and to be derived from working models that stem from experiences with other people during earlier years, rather than from current experience, how the patient perceives and conceives the analyst is often known as transference'. When an analyst interprets the transference situation he is, among other things, calling the patient's attention to the nature and influence of those models and, by implication, inviting him to scrutinize their current validity and,perhaps also, to revise them.
"Seen in the perspective of Piaget's theorizing, the concept of transference implies, first, that the analyst in his caretaking relationship to the patient is being assimilated to some pre-existing (and perhaps unconscious) model that the patient has of how any caretaker might be expected to relate to him, and, second, that the patient's pre-existing model of caretakers has not yet been accomodated - namely, is not yet modified - to take account of how the analyst has actually behaved and still is behaving in relation to him" (5).
Afterwards, in agreement with Guidano and Liotti (1983), the techniques of Rational Emotive Therapy (6) were employed to bring out and discuss Z's convictions about the world, herself and others:
"I must absolutely be loved and respected by everybody, and I always have to behave perfectly, otherwise it means I'm a damn fool* and I'll wind up alone and abandoned."
"... I've discovered that I spend the whole day in a desperate effort to get people to love me."
"... it's a silly rule because I know it's a mistake, and that to be loved by everybody is not realistic, and that it's also impossible."
"... there's a right way to do things, and whoever doesn't do them that way should be punished."
"... when a person doesn't behave the way I think he should, I get a lump in my throat, I feel a sense of oppression in my chest, blood rushes to my head, my colon swells up, I have a sour taste in my mouth, and feel nauseous."
The expression used here and elsewhere by the patient in the original Italian is "...sono una stronza", which translated literally would be "...I'm a turd". The translation "damn fool" was chosen because in present-day Italian usage "stronza" is far more common and less transgressive, especially in the mouth of a middle-class woman, than is the word "turd" in English (translator's note).
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"... I apply to others the same rules I apply to myself (...) Even in my relations with my own family, I want them to be perfect and so if I see myself or one of the others making a mistake I have an attack of anxiety."
Here we see how Z goes back to repeating the same convictions on the content emerging from the previous reflections, thus creating a vicious circle perpetuating her negative conclusions about herself and the world around her.
"... I was on the porch when I saw a strange man in the garden picking things up off the ground. He looked at me, I got scared and went inside. Then I reproached myself for being scared, and I said to myself, "if I were easy-going and brave I would have looked him in the eye and asked him what he was doing. Since I ran away I'm a damn fool. Later on, I thought it over and said to myself, "And what if it had been the person who rang the doorbell yesterday, when I didn't open? Maybe it was a maniac hanging around the neighborhood and checking out my window, which is on the second floor. He might be able to climb up and get into the house, and so on. I see myself while I'm thinking these things and I feel guilty -1 get anxious and it's my own fault because I imagine all these things - I'm a damn fool -1 don't want to be afraid, I want to be brave, I should have looked at him with a pleasant expression and said, "What are you looking for, sir?" I've had fantasies where I see him coming in through the window with a bad look on his ugly mug, and I say to him, nice and easy, Hello, what can I do for you?
"... I sometimes wonder if it's my fault that I'm such a silly bitch or whether it's the other people who don't want me around." When I blame others, I get mad and break the rules, then I feel guilty."
"... all these sentiments come to me automatically, just about anything sets them off, and they come."
Later, these automatic thoughts and the interior dialogue come out when Z meets a person she likes:
" ... on the street, I meet a person I like. I see him and wave to him enthusiastically from a distance. I'd like to stop him and offer him a cup of coffee, but I don't know if I should or not. It doesn't appear to be seemly. He doesn't give a shit about me, let alone accepting a coffee from me. I feel ridiculous, he might say he hasn't got the time and I'd feel rejected. I have a fantasy in which I see myself in the fit of enthusiasm, 'Hi, how're you doing?' - I'm all enthusiastic and happy, and he looks at me with a poker face, with indifference -1 immediately panic and turn away to look
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at a store window. I don't know if he heard me. Now I'm waiting for him! But what'll I do? Shall I stop? No, I won't wait for him, otherwise he'll think I'm waiting because I want to meet him. I'd better not get so enthusiastic, I know how it's going to turn out. I'm deceiving myself. I might be misunderstood and considered a bothersome bore. If I stop, I'm pretending, I'm resorting to tricks. But why the hell am I stopping and resorting to tricks just to meet him, and then what do I care? I slow down, and then I speed up, walking away. My fit of enthusiasm wouldn't be noticed, just what I thought! I get a sharp pain in my stomach and feel nauseous."
She then describes the process of acquiring the convictions she holds:
"... these sentiments remind me of what I went through as a little girl."
"... I can't stand people telling me how I should or shouldn't do things. My mother has always been that way. I have to defend my individuality; even when I was at boarding school everybody told me what I was supposed to do, and I always did the opposite."
"... my mother has always expected a lot of me, and has always been unsatisfied (...). If she was never satisfied, but always disappointed, I had to get better and better, and maybe the goal I set for myself was to become perfect, maybe to earn my mother's praise."
"... my mother considers me a good-for-nothing. She says, "Get out of the way, you don't know how to do anything right."
"... even when I was at boarding school I wanted to be perfect. There were signs up all over the place saying "God is watching you". I imagined myself being observed by God's eye, like a triangle shining in the dark. I thought, I don't have to do right in the sense of respecting the Ten Commandments, but I must be perfect even when I'm by myself."
"... even the rule about not trusting others comes from my mother. She said, "Don't tell other people about your private life, because they take advantage of this" (...) then I remember that if I took my aunt into my confidence, my mother always made a scene because she was jealous. Once "you'll get in trouble if you tell your aunt how much you paid for that handbag. She's going to criticize you."
"... as far as my family is concerned, I felt abandoned (...) my mother and sisters, who were grown up, kept me out of their conversations, saying I couldn't
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understand ("don't say it now because Z is here"). They kept me out of all their things and censored everything. They didn't let me watch TV, or they took my books away from me and I used to get really angry."
Discussion
In April 1990, Ms Z was given the A.A.I. It is to be noted that at that time Z had just met the man with whom she continues to live and who is the father of her child. Diagnosis of the A.A.I., which was blind tested by another attachment analyst (7), revealed a "state of mind" of the "unresolved mourning type in a secure pattern of attachment" according to the Main and Goldwyn system of analysis (8). More in detail, it can be said that while the diagnosis of the state of "unresolved mourning" caused no difficulty, it was more arduous to evaluate the "state of mind" of the main organization of attachment patterns, since the feelings of guilt that led to the diagnosis, albeit attenuated by a certain awareness, were evident, and attitudes, both of the "dismissing" and "entangled" types were noted. The fact that these attitudes were englobed by sufficient metacognitive monitoring allowed a diagnosis of an "autonomous" or "secure" type, which did require, however, the need to resort to a double classification. In symbolic form, the diagnosis for Z was "U-F1/F5", where "U" indicates the state of "unresolved mourning" and F1 indicates features characterizing the personality subgroup considered "secure" in the Main and Goldwyn system. Although there is a "dismissing" attitude, usually connected with difficult personal episodes during girlhood, Z has re-evaluated her life and has directed it in terms of a search for an affective life, despite the knowledge that there are difficulties involved in structuring satisfactory affective relationships. Subgroup F5, on the other hand, describes those personalities who still resent their families, but in a knowledgeable fashion, which is often marked by a certain humorism.
With this system of analysis, a diagnosis of what might have been the patient's "state of mind" in the first period of therapy was attempted on the basis of the clinical material collected. Although this operation may be considered arbitrary, it is felt that in the analytical monologues the "derogatory" attitudes characterizing "dismissing" personalities described by Main and Goldwyn, as well as the characteristic personalities defined as "entangled", emerge quite clearly. Still more evident are indications of "unresolved mourning" as compared to what emerged during the A.A.I, in 1990. We thus hypothesized a "state of mind" for the first part of the therapy at the limit of the capacity of the Main and Goldwyn classifying system, describable as "CC-U-Ds2-Ds3/E2". In this definition, the contemporary presence of "dismissing" and "entangled" elements is described by "unclassifiable" (CC = cannot classify), to
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indicate most of all the incompatibility of the contemporary presence of two irreconcilable patterns of attachment.
The pattern of attachment of Z's child was evaluated in February 1992, when he was 12 months old. The diagnosis of the blind strange situation test performed by Mary Main did not fail to reveal the kind of problems described in the analysis of the mother. The diagnosis posed by Main was "D-B2" or, alternatively, "unclassifiable". The letter "D" in the diagnosis of the pattern of attachment in children of 12 months of age, performed by means of the strange situation method, shows behaviors of the "disorganized/disoriented" type, which can usually be correlated with the parent's situation of unresolved mourning (9). In this case, the child's slow movements at first led Main to consider him as "B2 depressed", that is, with a behavior of attachment of the secure type, but with a situation of depression in progress.
Following a careful analysis, Main found stereotypes and the presence of behaviors of the "avoiding" and "resisting" type, the latter in reality far less pronounced than the former, in my opinion. This "avoiding" behavior, occurring only in the fifth episode of the strange situation, but not in the eighth, led to the child's being placed in category "B", that is, secure, but in subgroup "B2".
Conclusion
This case reveals the transgenerational transmission of the behavior of attachment and shows how sensitive these methods of evaluation are in highlighting the behavioral aspects that tell the story of affective interactions among people.
In this case, the application of the methods allowed the monitoring of the therapy as it progressed and its orientation towards specific themes. I wish to emphasize the fact that despite the difficulties that arose in the case described, the methods for evaluating the behavior of attachment, both in the child and in the adult, proved to be effective in revealing even those behaviors that had in time been attenuated by the psychotherapeutic work performed. These methods are considered to have led to the identification of a first change towards a "state of mind" relating to attachment of the "secure" type. At the beginning of her therapy, Ms Z appeared to have made up her mind to live alone, and considered psychotherapy simply the instrument for becoming insensitive to delusions and solitude.
Her change thus appears to be radical from the behavioral and affective viewpoints. At present, although she is still suffering from the same problems, and in a certain sense expects to have to face even greater dangers, both to herself and to
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the people close to her, Ms Z has found that the work done in therapy helps her to deal with her problems with more security than before.
We are now beginning to analyze the moments of interaction with her child, which may be implicated in the psychopathology of behaviors of the "disorganized/disoriented" type shown by the child. Thus, Z reports: "while I'm playing normally with my son, suddenly I get horrible thoughts, like he is going to die of some bad disease, or I think about my dead brother. At those times I feel sorry for him. Then I suspect he's aware of these feeling of mine and I feel guilty and get depressed, because I realize that at those times I look away from him" (10).
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NOTES
1) Bowlby J., Una Base Sicura - applicazioni cliniche della teoria dell'attaccamento. Raffaello Cortina Editore, 1989.
2) Main M., Kaplan N., George C, "Adult Attachment Interview" Department of Psychology, University of California, Berkeley.
3) Fonagy P., Moran G., Steele M., Steele H., L'integrazione della teoria
psicoanalitica e del lavoro sull'attaccamento: La prospettiva intergenerazionale.
in: M. Ammaniti, D. N. Stem, Attaccamento e Psicoanalisi, Laterza, 1992
4) Guidano V. F. & Liotti G., "Cognitive and Emotional Disorders", Guilford Press, New York, London, 1983.
5) Bowlby J., "Separation, Anxiety and Anger", Basic Books, Harper Torchbooks, pp. 205-206
6) De Silvestri C.,ll fondamenti teorici e clinici della Terapia Razionale Emotiva", Astrolabio, 1981.
7) I wish to thank Dr. Antonio Onofri of the Associazione A.R.PAS. of Rome for his collaboration in this work.
8) Main M. & Goldwyn R., "Adult attachment rating and classification system", Unpublished scoring manual, Department of Psychology, University of California, Berkeley.
9) Main M. & Solomon J., "Procedure for identifying infants as disorganized during the Rinsworth Strange Situation", in Greenberg M., Cicchetti D., Cummings M. (Eds), "Attachment in the Preschool years", University of Chicago Press, Chicago, 1990.
10) Main M. & Hesse E., (in press) "Parents unresolved traumatic experiences are related to infant disorganized attachment status: is frightened and/or frightening Parental behavior the mechanism?", in Greenberg M., Cicchetti D., Cummings M. (Eds), "Attachment in the Preschool years: Theory, Research and Intervention", Chicago, University of Chicago Press.
Translation by David C. Nilson
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