PSYCHOANALYTIC INQUIRY

2017, VOL. 37, NO. 5, 275–280

https://doi.org/10.1080/07351690.2017.1322417

Prologue: Creative Attachments: Clinical Practice Through an

Attachment Theory Lens

On being invited to edit an issue of Psychoanalytic Inquiry, the topic that immediately sprang to
mind was the use of attachment theory and research in clinical practice. Why did I settle so quickly
on this particular theme, when there is a plethora of other clinically relevant subjects that I might
well have chosen instead? My decision was influenced, at least in part, by the fact that my clinical
practice with adults (individuals and couples) is centrally informed by attachment theory and
research. This, in turn, reflects the fact that attachment ideas and empirical findings inform many
new ways of thinking about clinical issues and the therapeutic process: for example, the Boston
Change Process Study Group (BCPSG)’s work on the nonverbal implicit/procedural domain of being
and relating, Beebe and Lachmann’s adult treatment model, Allan Schore’s neurobiological approach
to affect regulation and cumulative developmental trauma, Bateman and Fonagy’s mentalization-
based treatment of borderline personality disorder, Joseph Lichtenberg’s thinking about motivational
systems and adult sexuality and sensuality, Giovanni Liotti’s understanding of the cognitive-devel-
opmental and motivational basis of dissociation and multiple self-representations, Alicia Lieberman’s
development of psychoanalytic infant-parent psychotherapy, Arietta Slade’s emphasis on reflective
functioning in conjoint work with parents and children and focus on narrative in work with adults,
Susan Johnson’s and Christopher Clulow’s approaches to working with couples, and Hazan and
Shaver’s research into the quality of adult romantic relationships.
Perhaps I should say that it is not always appreciated that research in the field of attachment
encompasses two main lines of investigation. Research utilizing the strange situation procedure
(Ainsworth et al., 1978) and the Adult Attachment Interview (George, Kaplan, and Main, 1996)
tends to focus on the intergenerational transmission of patterns of attachment organization between
caregiver and child. By contrast, research employing the Relationship Questionnaire (Bartholomew
and Horowitz, 1991) and the Self-Report Measure of Adult Attachment Styles (Brennan, Clark, and
Shaver, 1998) is designed to reveal the social-cognitive dynamics affecting thoughts, feelings, and
behavior in adult romantic relationships. Proponents of this line of investigation argue that their
research methodologies identify and classify the individual’s adult attachment style on a dimensional
continuum. Discomfort with closeness and emotional intimacy lie at one end of the continuum,
anxiety about abandonment and rejection lie at the other end. I have found these ideas and findings
particularly helpful in working clinically with the attachment dynamics that motivate violence and
abuse in intimate relationships (Renn, 2003, 2006, 2008, 2012).
More generally, I think it important to emphasize that attachment classifications used for research
purposes are simply ways of describing and organizing implicitly encoded attachment phenomena. These
silent phenomena and the invisible processes and relational procedures they represent are the focus of
clinical work, not the classifications per se (Slade, 2004; Renn, 2012; Clulow, 2017, this issue; Wachtel, 2017,
this issue). Also, that attachment is relationship specific, with representational models of mother, father,
and other significant attachment figures developing separately, rather than there being one overarching
model of attachment (Steel and Steele, 2008). This empirical finding would seem to support the con-
temporary psychoanalytic concept of multiple self-states (Davies and Frawley, 1994; Bromberg, 1998).
But the main factor that led me to choose this particular theme is that, despite the extensive
literature on attachment, and the broad acknowledgement of the clinical relevance of this body of
knowledge, many practitioners seem to be at something of a loss when it comes to actually using

CONTACT Paul Renn, DSW paul_renn2003@yahoo.co.uk 13 Seaton Road, Twickenham, TW2 7AT, United Kingdom.
Copyright © Melvin Bornstein, Joseph Lichtenberg, Donald Silver
276 P. RENN

attachment theory to inform their clinical practice. This distinct impression is based on my long
experience of presenting seminars, webinars, and workshops to colleagues on ways of creatively
integrating attachment ideas and research findings within a broad psychoanalytic paradigm to better
understand our patients’ difficulties in living and the nature of therapeutic change. My hope is that
this issue will go some way toward remedying this lack. To this end, I have invited a number of
renowned clinicians and theorists who are intimately conversant with attachment theory and
research to illustrate the creative and idiomatic ways in which they use attachment ideas to inform
their everyday clinical practice. This goal is reflected in the title of this issue, “Creative attachments:
Clinical practice through an attachment theory lens.”
Before summarizing the main points of the articles presented in this issue, a brief word of
explanation regarding the contributors’ gender is necessary. The reader will doubtless have noted
that, with the exception of Peter Fonagy’s co-author, Chloe Campbell, all the contributors are men.
Regrettably, for a variety of personal and professional reasons, the female authors and clinicians I
had invited to contribute to this issue were not in a position to accept. The resulting gender
imbalance is partially righted by the fact that these authors have cited many of the rich and erudite
contributions of distinguished female clinicians and researchers in the field of attachment.
Returning to the theme of this issue, John Bowlby launched attachment theory in the late 1950s,
motivated, in part, by a desire to provide psychoanalysis with a sound empirical foundation (Holmes,
1996). In the intervening 60 years or so, attachment theory and psychoanalysis have been uneasy bed
fellows. Indeed, Fonagy (2001), in his “bad blood” preamble to Attachment Theory and Psychoanalysis,
observed that Bowlby’s ideas “led to a line of empirical investigation that served to distance attachment
theory further and further from psychoanalysis, separated not just by a novel orientation to under-
standing clinical cases but also by an incompatible epistemology” (pp. 3–4). More recently, however, a
gradual but inexorable rapprochement has become apparent, as reflected in Mitchell’s (2000) state-
ment: “At this point in the evolution of psychological ideas, attachment theory and psychoanalytic
theory, rather than offering alternative pathways, offer the exciting possibility of a convergence that is
mutually enriching” (p. 102). In this context, Mitchell observed that “the emphasis in recent con-
ceptualizations of attachment bears close resemblance to the importance in recent psychoanalytic
theorizing of the themes of hermeneutics, constructivism, and narrativity” (p. 85). Moreover, the
process of rapprochement and convergence has been facilitated by the empirical exploration of the
representational aspects of attachment (Main, Kaplan, and Cassidy, 1985), and by the trend in
contemporary psychoanalysis towards acknowledging the role that real-life events play in personality
development and psychopathology (Slade, 1999; Renn, 2012).
Fonagy and Campbell, in their article, “Bad blood: 15 years on,” revisit Fonagy’s (2001) earlier
thoughts about the feud that developed between attachment theory and psychoanalysis in the 1960s,
arguing that “mainstream psychoanalysis has learned to live with empiricism” (p. 281). However, they
acknowledge that disquiet about the implications of attachment research persists in some quarters. In
exploring the rapprochement between attachment theory and psychoanalysis, and the convergence that
has emerged from this process, the authors echo Mitchell’s relational perspective, emphasising the
“importance of interpersonal relationships as drivers of clinical phenomenology” (p. 281). They link
the concepts of attachment and mentalizing to epistemic trust, contending that secure attachment not
only enhances the capacity for mentalization, but also generates such trust. Given this, Fonagy and
Campbell argue that epistemic trust is a vital ingredient of the change process because it facilitates the
internalization of new social and relational knowledge needed to update or modify pre-existing repre-
sentations of the interpersonal world. More broadly, they contend that current dynamic theories stress
“the creation of the intrapsychic in the theater of the interpersonal” (p. 282). Indeed, they aver that their
epistemic trust model combines psychoanalytic and attachment ideas; that from this perspective “there is
no distinction between attachment and the psychoanalytic approach” (p. 282).
Morris Eagle is a major theoretician of both psychoanalysis and attachment theory. In line with
other major figures in the field, such as Holmes, Lichtenberg, Liotti, and Slade, he argues that
attachment theory should not be considered a specific, stand-alone therapeutic model, a position that
 PROLOGUE 277

would seem to be consonant with Bowlby’s own thinking (Liotti, 2017, this issue). Eagle’s article,
“Attachment theory and research and clinical work,” provides an excellent exposition not only of the
ways in which attachment theory and research can helpfully inform clinical work, but also of what
constitutes therapeutic action in the relationship between therapist and patient. In particular, he
emphasises the clinical imperative “to truly understand the factors that make it difficult for the
patient to experience the therapist as a secure base” (p. 287). In this context, he draws attention to
research into the issue of how the therapist’s and the patient’s attachment states of mind interact in
the therapeutic process. His article concludes with a summary of the important contribution that
attachment theory and research has made to our understanding of various forms of psychopathol-
ogy, emphasising the corresponding benefit of using such understanding to inform our clinical work.
Stephen Seligman expands on the theme of convergence in his article, “Recognition and reflection in
infancy and psychotherapy: Convergences of attachment research with psychoanalysis.” The use of the
term convergences, in the plural, in Seligman’s title “suggest possibilities for synthesis between the
apparently divergent one-person and two-person models” (p. 298). This sentiment reflects contemporary
psychoanalytic thinking, in that the therapeutic process is viewed as incorporating both intrapsychic and
interpersonal dimensions. As I noted previous, Fonagy and Campbell express a similar view in their article.
Seligman’s article emphasises the convergences between recent attachment research and contemporary
Kleinian theory, and the implications such developments have for our clinical work. He links these
convergences to an intersubjective perspective that highlights the importance of being recognized, held in
mind, and understood. These existential aspects of experience foster a sense of coherence and security in
personality organization and are constituted in our early attachment relationships, being dependent,
developmentally, on adequate mentalizing or theory-of-mind experiences between the caregiver and the
child.
Although Seligman is highlighting Bion’s conceptualizations here, Winnicott (1960, 1987, 1988) also
comes to mind in thinking about the intersubjective aspect of his article: specifically, Winnicott’s theory
of mirroring and observation that the child ceases to exist when the mother (caregiver) who is not good
enough fails to greet the child’s spontaneous gesture. The capacity for creative play and concomitant
development of the true self is thereby circumscribed and an overly compliant false self develops instead.
Seligman illustrates the different forms of psychopathology that may be seen in adult patients when the
capacity for metacognition/mentalization is tenuous and breaks down in the clinical encounter. For
example, the account of his work with Robert C depicts the gradual transformation that Mr. C made
from a nonreflective style of being and relating characterized by transference enactments and, in Bionian
terms, attacks on linking, to one in which he was more able to mentalize and entertain different
perspectives, both in his relationship with Seligman and in his everyday extra-analytic relationships. As
he notes, “Attention to the changing quality of Mr. C’s thinking supported the evolving process of
recognition” (p. 304).
Jeremy Holmes has written widely on the subject of integrating psychoanalytic and attachment
ideas, emphasizing, in particular, the connections between attachment theories and object relations
and Kleinian theories. As I have shown, Seligman also sees parallels between certain empirical findings
from attachment research and Bionian theoretical conceptualizations. Such connections are, perhaps,
not entirely surprising, given that Bowlby (1969), in developing attachment theory, acknowledged his
debt to Freud, Klein, Fairbairn, and the British object relations school. Indeed, he was particularly
influenced by Klein’s (1940) view that certain mental defences in childhood are directed against pining
for the lost object; but also by Fairbairn’s (1946) contention that human beings are object-seeking,
rather than pleasure-seeking, and that actual failures in the external world, as opposed solely to
unconscious phantasies, could produce the intrapsychic structures so graphically described by Klein.
Holmes’s article is entitled “Attachment, psychoanalysis, and the search for a 21st-century
psychotherapy practice.” His central aim here is to “show how attachment theory, buttressed by
findings from contemporary neuroscience” (p. 309), can illuminate the way in which psychotherapy
brings about change. To this end, he explores several key themes and techniques “to show how
dialogue between attachment theory and contemporary psychoanalysis provides pointers toward an
278 P. RENN

emerging 21st-century psychotherapy” (p. 309). He illustrates how these themes and techniques, or,
conversely, the momentary lack of them, informed his clinical work with his patient, Tom.
Specifically, he shows how an attachment-informed approach helped him to repair a rupture or
mini-impasse that had arisen in the relationship between him and Tom as a result of his making a
clumsy, unattuned interpretation.
In concluding his article, Holmes acknowledges Anna Freud’s critique of Bowlby, viz. that much
of an attachment-informed technique is not new. However, he stresses that what is new is the
empirical basis for such technique. In a similar way to Eagle (2017, this issue), he sees a strength of
an attachment-informed model as lying in it not being dependent on mere authority and uncorro-
borated experience. He describes the benefit accruing from the emerging convergence of the two
approaches thus: “Attachment theory and research has the potential to infuse … psychoanalysis with
scientific rigor; a century of psychoanalytic expertise can bring unparalleled experiential richness to
attachment’s deep understanding of intimate relationships” (p. 317).
Giovanni Liotti’s interest in the clinical application of attachment theory and research dates back
to the 1970s. This developed into a focus on the links between dissociative psychopathology and
disorganized attachment. In line with Arietta Slade and Joseph Lichtenberg, Liotti emphasizes and
expands on the view that human relatedness is underpinned by multiple motivational systems,
attachment being but one, albeit centrally important, system. The first section of his article, “The
multimotivational approach to attachment-informed psychotherapy: A clinical illustration,” sum-
marizes the evolutionary roots of Bowlby’s theory of attachment. He then briefly outlines current
knowledge of infant attachment disorganization and its developmental sequelae from the perspective
of evolutionary multimotivational theory. From this perspective, infant attachment disorganization
“is characterized by a conflict between the attachment system and the survival defense system during
the interactions with the caregiver” (p. 321). Liotti brings these various theoretical considerations to
vivid life with a rich and detailed case vignette of a sceptical and distrustful patient, Sara. In
describing the therapeutic process with Sara, he illustrates the way in which his profound under-
standing of, and sensitivity to, the nature and dynamics of attachment informed his thinking about
the therapeutic relationship and the content and timing of his clinical interventions.
Paul Wachtel’s introduction to his article, “Attachment theory and clinical practice: A cyclical
psychodynamic vantage point,” emphasises the multifaceted nature of attachment theory—that there
are “different versions of attachment theory” and that “each of us has our own Bowlby” (p. 332).
Given this, the version of attachment that any one of us places in the foreground will have “some-
what different clinical and theoretical implications” (p. 333). Wachtel’s own particular version of
attachment theory focuses on the ways that “the internal working models generated by early
attachment experiences are either confirmed or revised by later life experiences” (p. 333). His cyclical
psychodynamic model highlights the processes involved. From this perspective, he stresses the need
to understand the tendency in adult intimate relationships to recruit accomplices to maintain
attachment patterns deriving from early experiences. This is, indeed, consonant with Bowlby’s
thinking in respect of choice of adult romantic partner. Bowlby (1979, 1988) contends that such
choice is one of the most significant ways in which attachment patterns and early affectional ties are
maintained, particularly in instances of unmourned loss.
In line with Bowlby, Wachtel points to the pivotal role that anxiety plays both in the maintenance
of such patterns and in opening up new pathways for therapeutic intervention. He illustrates these
processes and the way attachment ideas informed his cyclical psychodynamic model in his clinical
work with Jenny and David, respectively. Reflective of his interest in integrative relational psycho-
analysis, he emphasizes that attachment is a two-person phenomenon, rather than the property of a
single individual. Thus, the patient’s attachment dynamics evoke particular kinds of responses in the
intimate partner that, in turn, influence the emotional and sexual quality of the relationship.
Speaking personally, I have found Wachtel’s cyclical psychodynamic model eminently adaptable
and therapeutically beneficial in work with couples (Renn, 2012).
 PROLOGUE 279

The subject of couple psychotherapy leads on to the final article in this issue. Christopher Clulow
has written extensively about an attachment-informed psychoanalytic psychotherapy with couples.
His article, “Before, between, and beyond interpretation: Attachment perspectives on couple psycho-
analytic psychotherapy,” examines aspects of the process of couple therapy through the lens of
attachment theory and research. In the first section, he summarizes the history of the transference
interpretation and explores the clinical implications of an attachment-informed approach that
expands the dynamic unconscious to include nonconscious information processing systems. In
this context, Clulow stresses the implicit/procedural dimension of internal working models and,
thus, the need to explore implicit relational knowing, as developed by the BCPSG. He contends that
it is the space ‘between’ the couple “that provides fertile ground for change” (p. 347). He also brings
a neuroscience and trauma perspective to his understanding of the ways in which early attachment
experiences “can interfere at a physiological level with brain functioning” (p. 347). Clulow contends
that such empirical data poses a challenge to “a fundamental basis of interpretations rooted in the
conception of a dynamic unconscious” (p. 347).
More generally, he argues that a relational emphasis provides a new kind of affective experience—
that the nonverbal, implicit aspects of the therapeutic relationship are as important as the verbal,
cognitive (interpretative) aspects. Indeed, he states that “Attachment theory challenges us to take
account of implicit communications” (p. 349). As noted, this consideration is in accordance with the
BCPSG’s ideas; with the narrative, meta-communicative focus that Arietta Slade brings to the
therapeutic encounter; and with the clinical significance of discrete discourse styles, as coded from
Adult Attachment Interview transcripts. Consonant with other contributors to this issue, Clulow
notes that the couple relationship is influenced by motivational systems in addition to attachment,
for example, the caregiving, sexual, and interest-sharing systems. He emphasizes that attachment,
caregiving, and sexuality are interrelated systems central to adult couple relationships. He illuminates
his attachment-informed couple psychoanalytic psychotherapy with a number of clinical vignettes.
That, then, concludes my outlines of the articles that comprise this special issue on the creative
use of attachment theory in clinical practice. I hope these summaries have whetted your appetite and
that you enjoy the rich and varied fare that our esteemed authors have served up for our delectation.

Paul Renn, DSW

Issue Editor

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