Off The Couch #5 Approach for Healing Attachment

Dr. Brown talks about his experience with healing attachment disturbances. He became certified in the Adult Attachment Interview (AAI). Over time, he developed the three pillars approach to treating attachment. In this interview, you will learn the three dimensions that help in healing attachment disturbances.

Read the Full Transcript:

Dan Brown: At the time, we were trying to understand the difference between attachment maps and core conflict relational maps. There was a famous line by Paul Chodoff, an analyst who said that the difference is between people who have trouble with relationships and people have trouble within relationships. And maybe that’s an oversimplification, but it always helped me to understand the difference between these two maps. And we got more interested in how to correct attachment disturbances, rather than just CCRT formulations. And what changed my life was I decided to learn the Adult Attachment Interview, the AAI. So, I invited one of the trainers, Debbie Jacobvitz from the University of Texas, to come up to Boston. I got a group of clinicians who I had known well to take a two-week intensive training course on the Adult Attachment Interview. And then, as a two-year certification process, there are 36 practice protocols that you have to work with, and they take about 20 hours each to analyze.

Caroline Baltzer: So, becoming an analyst almost.

Dan Brown: It’s a lot of work, and then there are 36 protocols you have to do in addition to that, which are for reliability checks. Three sets, in 12 protocols each, you submit to the originators of the protocol, Mary Main and Eric Hess, and they check the accuracy of your assessment against their own assessment of that. So, you have to get above 80% accuracy to get certified. And most people get certified because it’s so much work, you learn it so well that it works. So, I got certified, and about 500 people in the world are certified in this. It takes two full years of training.

Mary Main says that each of these different attachment prototypes: secure attachment, [avoidant] dismissing attachment, anxious preoccupied attachment, and disorganized attachment are associated with a unique state of mind, and organization of mind. So, just by how people describe their attachment experiences, if you learn to listen to the language, you can tell what the attachment map is for that person. And that changed everything because we began to think more in terms of how to enter into that world of the dysfunctional attachment map that the person had and to change it around. And over time, we developed three dimensions of treatment.

The first dimension of treatment was what we call “ideal parent figures.” Where that came from was this idea that insecure attachment is associated with an inconsistent or lack of the ability to form a positive internal working model, or a map for relationships. So, it seemed to me that therapists who interpreted all the dysfunctions of relationships weren’t helping the patient to develop a positive map, because the absence of a negative is not a positive, it’s just the absence of a negative. So, we began to focus more on ideal parent figures. “Imagine growing up in a family, different from your family of origin, with an ideal set of parents, each suited to you and your nature.” We had them shape and reshape the imagery for many sessions, so that, in carefully reshaping the imagery over time, they were developing a positive map. We call it “positive re-mapping” for attachment.

And the reason why we started focusing on that attachment map was for two-fold. One is that attachment behavior starts in the first days of life with a neonate, but the effects on all lines of development are the development of an internal working model of a relationship that happens in about 18 months. So, it’s not the attachment behavior on the part of the mother, it’s the child’s capacity to represent that attachment. There is an internal map that seems to have a stabilizing effect on relational development, self-development, and emotional development – the big three developmental lines.

And secondly, I got influenced by that because, when we were (some years earlier) working with treatments for psychotic individuals, I tended to focus on developing a cohesive sense of self in psychotic individuals and the capacity for genuine emotional experience. But a colleague of mine, Elgan Baker, out of the University of Indiana Medical School, was working on developing a positive representation of the therapist in people with psychotic or borderline conditions and found that, if they developed a new positive representation with a good- enough-therapist, then they were developing a new relational map. So, building on Elgan Baker’s work, we taught together for some time, we began to focus more on this ideal parent figure and took it from there.

Caroline Baltzer: He was working with schizophrenics and borderline personality disorder?

Dan Brown: Yes. And we took it from there and just tried to extend this focus on developing a positive map. What we found is that most therapists who were doing attachment treatment were trying to become a good attachment figure. And it’s arrogant to think that the therapist is going to be a good attachment figure. Most therapists didn’t have good attachment, so there were a lot of therapeutic ruptures in the treatment. And we found that, by using imagination, because imagination by definition creates new possibilities, you could shape and reshape the imagination around ideal parent figures until it felt just right. And you could keep doing that until they developed the positive map. It didn’t require the therapist to behave in certain ways, and it didn’t result in as many therapeutic ruptures.

Caroline Baltzer: And it freed the therapist up to be collaborative and not co-creation.

Dan Brown: Right. So, that was the first pillar of the treatment. And then, through the training in the Adult Attachment Interview, there was a scale on metacognition, but it was never well developed. I thought it needed to be developed more. Eric Hess and Mary Main promised they would develop a much more refined scale, but they never did. Who developed it was Howard Steele, Miriam Steele, Mary Target, Valerie Sinason, and Peter Fonagy, at the Tavistock Clinic. They developed a scale called Reflective Function Scale that measures metacognition in patients.

What Howard told me was that, if you scale this on -1 to +9, they never found a patient with a personality disorder diagnosis, or dissociative disorder diagnosis, who ever scored above 3 on that scale. And most people in the general population score about 4.5 – that is mildly metacognitive. The people who have been through years of psychoanalysis score 8 or 9 because they’ve trained themselves to observe their own internal states in front of another person. So, training metacognition turned out to be important in the treatment of borderlines, and other personality disorder patients, and dissociative disorder patients. And that evolved into a whole treatment at Tavistock called mentalization-based treatment. The outcome studies of that were very impressive.

The first studies in the West on the treatment of borderlines was Otto Kernberg’s work on transference-based therapy, who I knew at the time, at Menninger Foundation. That’s where he was before he moved to Cornell. But the outcome studies that were done in Europe showed that, in randomly assigned treatment – to either transference-based treatment, the Kernbergian approach as the traditional treatment, versus mentalization-based treatment and metacognitive treatment – in two years of treatment, the effect size of the metacognitive doubled that of the traditional borderline treatment. That’s an effective statistic.

And there was another study that was comparing mentalization-based treatment to DBT – Dialectical Behavioral Therapy – and in two years, 70% of the patients with mentalization-based treatment didn’t meet the diagnostic criteria for personality disorder. But all of the patients in DBT did. So, things that get popular are not necessarily the best treatments.

Caroline Baltzer: How do you explain that – the comparison between DBT and MBT in that study?

Dan Brown: The difference is what we’re training for metacognition. Marsha Linehan, when she developed dialectical behavior therapy (DBT), one of the core skills was what was called “mindfulness;” because she was interested in mindfulness meditation.

The third generation of metacognitive work was done in the Rome Institute of Cognitive Therapy. What they found was that there are different metacognitive skills that were deficient in different patient populations. So, one is called metacognitive awareness, the capacity to be aware of your and others’ feeling states, or internal states of mind. Another is called metacognitive mastery, the capacity to be aware in such a way that it has a regulatory effect on the feeling state. In their research, they found that borderlines had good metacognitive awareness. They were aware of their feeling states and others’ feeling states in a very acute way. But they weren’t very good at their cognitive mastery. So, they couldn’t be aware of the feelings in a way that would have a regulatory effect on the feelings. So, this idea of core mindfulness was not informed by research. It was something that Marsha Linehan was interested in, and she just assumed that that would be a core skill. However, the research done in Rome showed that you have to develop metacognitive mastery in personality disordered patients, not just metacognitive awareness.

And they developed a third one called metacognitive organization, or integration. So, if I say to a patient, “give me on a 1 to 10 scale – 1 being very little organization of mind, and 10 being a very organized state of mind, and the other numbers somewhere in between – what’s your level of organization of mind right now?” And they say, “6,” or they say, “3.” And if you ask that question four or five times a session, and you do that over the next six months, it shapes reorganization of mind in the direction of greater coherence of mind. So, we began to see that there was an approach to metacognition that was condition-specific to the diagnosis, not just a general function.

So, that was the evolution of my thinking in terms of metacognition. Then, finally, because of my friendship with Ken Wilber over the years, we wrote a book together in the 1980s. I got interested in post-formal metacognitive development. Piaget had a model of intelligence that went up as far as adolescence with formal operational thinking. And if we think that human intellectual development stops with adolescence, then we’re in trouble as a species. But a number of people have worked on postformal stages of cognition and metacognition. There are seven stages of postformal development. And we got interested in looking at that because the work on mentalization-based treatment is impressive as outcome studies, but all of it is based on pre-formal types of cognition and metacognition. So, we thought that looking at the post-formal types of cognition and metacognition would provide a greater range of skills to our borderline, and other personality and dissociative disorders, patients. So, most of those higher-level postformal cognitive and metacognitive skills have to do with different kinds of perspective-taking. So, the more you take a larger perspective in life, the more you get out of your own narrow pathology. And that was the culmination of our work on metacognition, to bring it to a more mature stage of development.

Caroline Baltzer: Maybe that’s why, for a lot of borderline personality disorder individuals, it’s so important to return to functioning life and have an interface with a lot of different things besides yourself, outside of your home, outside of what you’re familiar with, so you can increase your perspective-taking.

Dan Brown: Well, when I take on a personality disorder patient, a complex trauma patient, which I do a lot of in my private practice, one of the pre-conditions of the treatment frame is that they have a life outside of therapy, that they have a job, and if they can’t get a job, then they do volunteer work for at least that time.

Caroline Baltzer: I think that’s so significant.

Dan Brown: And I learned that when Margaret Brenman-Gibson came to Cambridge Hospital. She had come from Austen Riggs, and she, Bob Knight, and Eric Erikson had set up Austen Riggs, and then when she came to Cambridge, Erick Erickson came to Cambridge a lot. So, his wife, Joan, was the one who set up the program at Austin Riggs, so that everybody, all the psychotic patients at Austen Riggs, had meaningful work, and they all had hobbies that they engaged in, so they had passions in their daily lives, they just wanted therapy intensively. I was influenced by that model. I think that people need to get a life. No need to take a vacation from life to do trauma work. So, I strongly agree with that. So, the third pillar was on developing collaborative behavior, and I had read a paper by Giovanni Liotti, from the Rome School of Cognitive Therapy, about fostering collaborative behavior. I thought it was very impressive. So, I wanted to meet him.

I went to Rome to visit him. I drove in Rome and actually found him, which is a feat in itself, driving in Rome. And he was very friendly and open and shared with me his whole treatment approach. He told me to read Michael Tomasello’s work “The Social Anthropologist.” Michael had done 10 years of research on primates, silverback gorillas, and chimpanzees. And he found that chimps and gorillas will collaborate in collecting food, but they won’t share it very much. But what was unique in the evolutionary chain was that human beings will collaborate with all sorts of abstract projects at work, and that was the unique feature of humans.

The second thing that Michael Tomasello did was he looked at young children in playschool. He found that secure kids were naturally collaborative. They would share their toys; they would be more empathic for kids who were having a hard time in the playroom. Whereas insecure kids took their collaborative behavior offline. So, in his research, it was clear that collaborative behavior was part of the evolutionary plan of the human species. But people who have insecure attachment learn to suspend that collaborative behavior, and they need to be taught collaborative behavior again. They need to be taught how to focus and turn their head when they’re talking to somebody and show that they are listening. And they need to use verbal behavior to take turns.

Caroline Baltzer: It’s like a whole language they need to learn.

Dan Brown: So, people with anxious preoccupation don’t take turns, they just keep on talking over you. And people with [avoidant] dismissing attachment don’t show you with eye contact or head-turning that they’re actually engaged with you. So, we felt it was important to give that kind of feedback in a non-critical way to our patients with personality and dissociative disorders: to say, “Look, this is how you live in an interpersonal world.” It goes back to some of the early work of Harry Stack Sullivan on interpersonal psychiatry.

I remember when I was at McLean, my preceptor was the head of the hospital, Al Stanton, who was a part of the original class of 12 with Harry Stack Sullivan. I remember presenting a case that was very distressing to me. It was a patient. I would walk into her room to review her privileges with her, and she would make these blood-curdling screams as if I was bloodily raping her. And it took me several weeks before I was afraid to go into her room because she would scream rape all the time, and it was embarrassing.

So, I went to talk with Al about it, and he was a good Harry Stack Sullivan interpersonal psychiatrist. And he said to me, “Tell her to shut up.” I said, “What?” He said, “Tell her to shut up. Say: stop screaming, listen to me, and learn to talk human.” He said, “you’re not doing her any favors if you don’t do that. She is never going to learn to live in an interpersonal world.” So, based on what he told me, I went in there, marched with this confidence into the room, and said, “Stop screaming right now.” And she said, “What did you say?” I said, “Stop screaming right now and sit down and talk to me as a human being and make sense.”

Caroline Baltzer: It caught her attention.

Dan Brown: “And work in making sense,” and she said, “Okay.” She was silent for a few minutes. She said, “You know, I was afraid this week.” And it stunned me, however simple it was. It never occurred to me in a million years to treat her as a human being and ask her to take turns to engage in normal human dialogue. So, we eventually built that into our attachment treatment.

Caroline Baltzer: Anthony Bateman is so good at doing that in his role plays in the MBT model.

Dan Brown: It’s important. So, that’s how we evolved the three pillars treatment, which you were very much a part of. And then, the last part of the treatment was to work out unique treatment interventions for each of the specific subtypes of insecure attachment. There’s one protocol for [avoidant] dismissing attachment, there is one for anxious preoccupied attachment, there is one for disorganized attachment, and they are all quite different. And that’s probably the unique contribution of the three pillars treatment. They’re all uniquely designed for that given type of subtype of attachment.

Caroline Baltzer: Yeah. It’s like a cookbook, you can go and look up what you need to treat. And there it is, with the explanation behind it.

Dan Brown: It took 20 years to evolve these, as you know. So, that’s what I would say about our attachment treatment.

Watch the full clinical interview series:
1. Meet Dr. Daniel P. Brown
2. Overview of Trauma Treatment
3. Attachment Disturbances 
4. CCRT (Core Conflictual Relationship Themes)
5. Three Pillars Approach (Treatment for Healing Attachment)
6. Teaching Psychology
7. Conversion Disorders
8. Factitious & Dissociative Disorder
9. Psychological Assessments
10. Bipolar Disorder Treatment
11. Trauma Bonding Maps
12. Conclusion

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