At The Menninger Clinic we think a lot about relationships – how they are nurtured, how they are compromised and how they can grow with steadfast care and attention. As this Father’s Day approaches, thinking about the relationship I am forming with my baby girl – now fast approaching her first birthday – fills me with awe.

I had heard that becoming a father can be a major thrust for a man’s development; little did I realize how true that would be. For me, it began the moment I heard my daughter’s first cry and held her little hand. Some joke that my daughter has had me wrapped around her finger since birth – and they’re right!

Babies do not come with their own instruction manual. It was my job to learn my daughter’s ways and to learn how to relate to her – as a bigger human. This required me to be in the moment and be emotionally present. It meant making the effort to try and understand the nature of her cries and to respond to them empathically. Suddenly, I was the novice again. We call this the “not knowing” stance of mentalizing, or, more simply, trying to understand what makes our kids tick.

I have been enthralled but vulnerable, unsure yet committed. I have found it takes a whole lot of devotion to get up night after night, exhausted, to be present when my little girl is hungry or needs her diaper changed. I have grown into a more patient and compassionate man. I better understand the importance of the environment that I nurture for children – and adults.

But being a dad is also about enjoyment and celebration. It has been about being there to witness my daughter’s first tooth sprout or to hear her first laugh or to help her pet her first puppy. The whole world is new and full of wonder for her – and it becomes new to me, too! We celebrate the simple beauty of a tree leaf, the blue sky or the wind. I fondly remember my daughter trying to taste the wind when she first felt it on her face. Children so beautifully capture openness to experience and curiosity.

Being a dad involves a whole new chapter of lessons and adventures on being human, and I see a lot of parallels in my relationships at Menninger. Like being a father, I strive to learn my patients’ ways, and along the way I laugh, I cry and I worry, but most important, I truly care. Devotion matters. It is what sustains my connection to my daughter, as well as my patients and colleagues. It helps us hang in there through the exhausting and trying times.

To me, Father’s Day honors the role men play in nurturing and caring for others, and the ways they can serve as secure attachment figures for children and others. I am thankful my daughter provides me the thrill of learning to attach all over again.

I had the good fortune recently to participate in a think tank and conference in The Netherlands with Jim Coan, a talented clinical psychologist at the University of Virginia who is conducting pioneering neurobiological research on attachment. I think the results of his research have profound implications for stress management and for treatment; I inform patients about his work every chance I get.

Clever experiment

Jim and his colleagues¹ conducted a remarkably clever experiment with married couples published with the inviting title, “Lending a Hand.” The couples were carefully selected to be highly satisfied in their marriage. In the experiment, the women were exposed to a stressful situation: They had electrodes fastened to their ankles and periodically were given electric shocks. Before the shocks, they were given one of two signals:

1. a safety signal indicating that they would not be shocked or 
2. a threat signal indicating that there was a 20 percent chance of being shocked (and they were shocked on some trials).

This procedure enabled the researchers to compare patterns of the women’s brain activity (with functional magnetic resonance imaging) under two conditions:

1. when they were feeling threatened versus 
2. when they were feeling safe.

Here is the clever part: at different points during the threatening procedure, the women were permitted to hold their husband’s hand, a stranger’s hand or no one’s hand. Also of interest, even though these couples were highly satisfied with their relationship, the researchers assessed differences in degree of satisfaction within the group (i.e., more satisfied or less satisfied). These differences make a difference.

Complex results

The details of the findings are complex, as the researchers studied more than a dozen different areas of brain activity. In broad terms, they studied activity in areas that indicate emotional response to threat as well as areas that are known to regulate or control emotional distress. Complex as they may be, the gist of the findings is elegant and important: the more the woman was on her own while she was feeling threatened, the greater the number of brain areas showing elevated activity. The brain was least active when the woman was holding her husband’s hand and most active when she had no hand to hold. Moreover, even though all couples had a good relationship, the women who were in a less satisfying relationship showed more elevated brain activity when holding their husband’s hand than those who were in a more satisfying relationship.

Efficient distress management

Jim came to a simple conclusion: When we are threatened, a feeling of connection with a person to whom we are securely attached is our most efficient way of regulating distress. His social baseline theory² proposes that we humans are hard-wired to use social proximity as a default strategy for regulating emotional stress. He also notes that we share this default strategy with many other mammalian and bird species. This strategy evolved not only because there is safety in numbers but also because reliance on trusted companions for help and support lessens the load on our individual resources. True, we must learn to manage distress on our own to a considerable degree. Ironically, one of the best ways to cope with emotion is to be tolerant and accepting of emotional distress; fighting it makes it worse.³ But the experiment’s results demonstrate clearly that managing on our own—however we may do it—is a costly strategy; it is effortful. Attachment can cut off stress at the pass. Mere proximity to another person in a threatening situation is of some help, but proximity to a familiar person is more help and proximity to a trusted attachment figure is most helpful.

Extensive neuroimaging research shows that the prefrontal cortex plays a major role in regulating stress. The prefrontal cortex also uses a great deal of energy. Hence we can conserve energy by relying on attachment relationships—to use an apt economic metaphor, we “outsource” stress regulation to our social networks.⁴ This attachment strategy frees up brain resources to engage in problem solving: We have more capacity to deal effectively with the source of threat if we don’t have to invest so much energy in regulating our distress. Being more accepting of stress rather than trying to suppress it might be one way of conserving some energy. But attachment is another. Yet there is a caveat: The attachment strategy works best when the partner is emotionally attuned, as partners in highly satisfying marriages are likely to be. Seeking comfort from someone to whom you are insecurely attached is liable to increase stress.⁵

It’s best to let Jim speak for himself; he neatly summarizes his thinking as follows: 

The social baseline model proposes that social forms of emotion regulation are not ‘down-regulatory’ in the same sense as self-regulation efforts. Rather, it proposes that social resources alter perception-action links associated with intervening in the environment, such that there is less perceived alarm when perceived social resources are high, which corresponds in turn to fewer actions needed to meet demands associated with the stressor. This, I have argued, conserves metabolically costly operations in the prefrontal cortex and elsewhere, either by simply conserving neural resources or freeing them to be devoted to other problems, thus increasing the efficiency of coping with a potentially dangerous and uncertain world.^{2(p. 620)} 

Implications for practice

I find especially provocative a point he⁶ makes about the implications of this theory and research for clinical practice. We put a lot of effort into developing treatment methods to help patients become more adept at self-regulation of emotions. Prominent examples include mindfulness practice,⁷ dialectical behavior therapy⁸ and cognitive-behavior therapy.⁹ No doubt, we all need to be adept at self-regulation; we can’t be holding our attachment figure’s hand whenever we feel threatened! Yet self-regulation is not the most efficient or powerful means of emotion regulation. Accordingly, we should be putting as much—or more—effort into developing treatment approaches that enhance attachment relationships and promote security in those relationships.

In the past decade, considerable effort has gone into applying attachment theory and research to psychotherapy.^10-14 Yet, now buttressed by Jim’s research, Sue Johnson^{15, 16} has made a compelling case for working on attachment relationships directly in marital, couples and family therapy to enhance emotional connection and security—handholding that works. Thanks to evolution, we have a remarkable ability to rely on attachments to manage stress by merely feeling connected. My advice: Strive to develop, maintain and make full use of secure attachment relationships, and give your overworked brain a break—and your body as well, given the toll stress takes on your health. 

References 

1. Coan JA, Schaefer HS, Davidson RJ. Lending a hand: Social regulation of the neural response to threat. Psychological Science. 2006; 17:1032-1039.
2. Coan JA. The social regulation of emotion. In: Decety J, Cacioppo JT, eds. Handbook of social neuroscience. New York: Oxford University Press; 2011:614-623.
3. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford; 1999.
4.  Coan JA. Adult attachment and the brain. Journal of Social and Personal Relationships. 2010; 27:210-217.
5. Mikulincer M, Shaver PR. Attachment in adulthood: Structure, dynamics, and change. New York: Guilford; 2007.
6. Coan JA. Toward a neuroscience of attachment. In: Cassidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and clinical applications (Second Edition). New York: Guilford; 2008; 241-265.
7. Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Delta; 1990.
8. Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford; 1993.
9. Barlow DH, Allen LB, Choate ML. Toward a unified treatment for emotional disorders. Behavior Therapy. 2004; 35:205-230.
10. Allen JG, Fonagy P, Bateman A. Mentalizing in clinical practice. Washington, DC: American Psychiatric Publishing; 2008.
11. Holmes J. Exploring in security: Towards an attachment-informed psychoanalytic psychotherapy. New York: Routledge; 2010.
12. Obegi JH, Berant E, eds. Attachment theory and research in clinical work. New York: Guilford; 2009.
13. Slade A. The implications of attachment theory and research for adult psychotherapy: Research and clinical perspectives. In: Cassidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and clinical applications (Second Edition). New York: Guilford; 2008; 762-782.
14. Wallin DJ. Attachment in psychotherapy. New York: Guilford; 2007.
15. Johnson SM. Couple and family therapy: An attachment perspective. In: Cassidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and clinical applications (Second Edition). New York: Guilford; 2008; 811-829.
16. Johnson SM, Courtois CA. Couple therapy. In: Courtois CA, Ford JD, eds. Treating complex traumatic stress disorders: An evidence-based guide. New York: Guilford; 2009; 371-390.

Two voles

It’s been nearly four decades since I traveled to the University of Illinois with my wife to visit her former biology professor, Lowell Getz. I was bemused by his interest in voles—small rodents resembling mice, of which there is a multitude of species. I remember watching them scurrying along the fence rows. Why anyone would want to devote a career to studying them escaped me. In what has become a common experience, I was taken aback by my ignorance when I discovered recently that Getz and his colleagues¹ were pioneering research in my main area of interest, attachment theory.

Voles 101

Differences between two species of voles have garnered the attention of attachment researchers. Prairie voles are monogamous; they form enduring pair bonds, analogous to romantic relationships in us humans. Prairie voles provide biparental care to their young, and they’re loyal: if they lose a mate, they don’t take another partner. They get attached. In contrast, nonmonogamous meadow voles are promiscuous; they don’t form partner preferences. They don’t get attached. The differences between prairie voles and meadow voles are neatly tied to the neuropeptide oxytocin and a closely related neuropeptide, vasopressin.² Both neuropeptides facilitate pair bonding, although oxytocin plays a more important role in females and vasopressin in males.

Love and attachment

Oxytocin facilitates maternal behavior—in delivery by facilitating intrauterine contractions, and after birth by triggering milk letdown. Oxytocin also promotes infants’ attachment to their mother. Thus oxytocin plays a widespread role in attachment, facilitating infant attachment, maternal bonding and adult attachment (pair bonds). Handily, oxytocin stimulates brain reward circuits, including those involving endogenous opioids (natural narcotic-like substances in the brain). Thus oxytocin renders attachment relationships pleasurable and soothing.³

A quick look at the literature

Research on the influence of oxytocin on human social behavior has been made easy by the fact that intranasal inhalation boosts brain levels of oxytocin temporarily—a few puffs in each nostril will do. Here’s a brief sampling of recent studies demonstrating the social effects of sniffing oxytocin:

• When we see a threatening picture such as an angry face, a brain structured called the amygdala immediately becomes activated. Our amygdala not only detects threat but also orchestrates our fear response. Thus trauma researcher Bessel van der Kolk dubbed the amygdala the brain’s smoke detector. Recently, researchers administered oxytocin or placebo to participants before they were shown threatening pictures. Compared to placebo, oxytocin decreased amygdala activity and dampened the fear response.⁴ Under the influence of oxytocin, we can feel less threatened by others.
• Persons with social phobia typically show exaggerated amygdala responses to threatening social cues such as fearful faces. Researchers found that administering oxytocin normalized amygdala responses in persons with social phobia, that is, reducing their hyperactive amygdala responses.⁵
• Researchers study trust by putting participants into the role of “investors” and giving them the option of transferring part of their holdings to a person placed in the role of the “trustee.” Investors can maximize their gains by transferring more money to trustees—but only if trustees reciprocate by sharing their earnings. Under the influence of oxytocin, investors show greater trust and willingness to take social risks: they transfer more money to trustees.⁶
• Simon Baron-Cohen developed the Reading the Mind in the Eyes Test to measure participants’ capacity to understand others’ emotional states, a component of mentalizing ability.⁷ This is a multiple-choice test in which participants are shown photographs of the eye region of the face and asked to identify what emotion the individual is feeling. Sniffing oxytocin improved performance on this test, implying that oxytocin is an empathy amplifier.⁸
• Researchers exposed a group of men to a threatening social situation, namely, a mock job interview conducted by a panel.⁹ Just prior to the interview, one group had the benefit of social support, that is, the presence of their best friend. The other group had no such support. Some participants also sniffed oxytocin prior to the interview. Participants’ level of distress was measured by their level of stress hormones after the interview. Both social support and oxytocin decreased stress, but their combination was best. In short, oxytocin enhanced the stress-reducing function of social support.
• One of the studies of attachment that has made the greatest impression on me was conducted at the Baylor College of Medicine by our colleagues Lane Strathearn and Peter Fonagy and their colleagues.¹⁰ The study compared mothers who showed evidence of secure attachment in adulthood with those who were insecurely attached. Compared with those who showed insecure attachment, securely attached mothers showed higher levels of oxytocin after interacting with their infant in a play situation. In a later phase of the study, the mothers were shown pictures of their infants’ happy faces as well as their sad faces. Compared to the insecure mothers, those who were secure showed higher levels of activity in brain-reward circuits when viewing pictures of their infants—not only when the infants were happy but also when they were sad. In contrast, when viewing the face of their sad infant, the insecure mothers showed activation in brain areas suggesting higher levels of emotional distress as well as efforts to inhibit this distress. The secure mothers’ characteristically higher levels of oxytocin when interacting with their infant were believed to contribute to this difference, enabling them to stay engaged with their distressed infants. The mother’s capacity for engagement is crucial, because it enables infants to become securely attached—confident that their mother will be psychologically attuned to their distress, that is, mentalizing.

For those of us who place a high value on secure attachment relationships, oxytocin seems to be a natural wonder drug. Indeed, it’s been dubbed the hormone of love. Musing about the potential of psychotherapy to promote attachment, renowned neuroscientist Jaak Panksepp wondered if therapists and their clients might benefit from intranasal oxytocin administered prior to therapy sessions.¹¹ Was Panksepp serious? I can’t tell from the way he wrote it. But if you see therapists and their clients sniffing something prior to therapy sessions, you’ll know someone took him seriously. I wonder if oxytocin might enhance the effects of POT (Plain Old Therapy). Using your imagination, the possible applications to human affairs are limitless.

On the other hand …

Unfortunately, additional research douses this utopian vision with some cold water while also shedding light on the sheer complexity of oxytocin’s influence on relationships:

• Shelly Taylor and her colleagues¹² found that oxytocin levels were elevated in women whose current attachment relationships were in a state of distress. Moreover, oxytocin’s  counterpart in men, vasopressin, was elevated when their attachment relationships were stressed. The authors speculated that these prosocial neuropeptides become elevated in the context of relationship distress to provide a biological signal to the distressed individual to seek support in other relationships.
• As expected, Jennifer Bartz and colleagues¹³ found that administering oxytocin led males to remember their mother as having been more caring and close. Yet there was an important caveat: this result held true only for those males who showed a general pattern of secure attachment in their current relationships. Under the influence of oxytocin, males who were insecurely (anxiously) attached remembered their mother as less caring and remembered being less close to her in childhood. The authors speculated that administering oxytocin activates attachment needs and that this activation has different effects depending on the security of attachment.
• In another study, Jennifer Bartz and colleagues¹⁴ studied the effects of administering oxytocin on trusting behavior in a game where participants played for money and had the option of cooperating or competing. Recall that oxytocin enhanced trusting behavior in a study I described earlier in this post.⁶ Bartz did a similar study but included participants with borderline personality disorder, a disorder associated with insecure attachment and unstable relationships, often owing to a fear of abandonment. In contrast to the usual findings, for persons with borderline personality disorder, administering oxytocin decreased trust and cooperation, an effect that was most pronounced in those participants who showed a high level of anxiety in attachments in combination with an aversion to closeness.

This glimpse of a burgeoning research literature shows that oxytocin plays a significant role in attachment—typically a salutary role. And it underscores a main function of attachment, namely, its role in providing a feeling of safety and security in the face of emotional stress. Most important in my mind is Strathearn and colleagues’ finding that securely attached mothers are able to remain positively engaged with their infants when their infants are distressed, and oxytocin may play a role in this crucial maternal ability. But the research also shows that sniffing oxytocin might heighten relationship problems for persons who are insecurely attached.

Perhaps we should not be surprised that there is no shortcut to secure attachment for those who most need it. As a society, we’re always on a quest for quick fixes and panaceas—drugs prominent among them. But secure attachment must be acquired the old-fashioned way, by good parenting, good relationships and—when enhancements are needed—POT (Plain Old Therapy).

References

1. Carter CS, DeVries AC, Taymans SE, Roberts RL, Williams JR, Getz LL. Peptides, steroids, and pair bonding. In: Carter CS, Lederhendler II, Kirkpatrick B, eds. The integrative neurobiology of affiliation. Cambridge, MA: MIT Press; 1999; 169-181.

2. Young LJ, Wang Z. The neurobiology of pair bonding. Nature Neuroscience. 2004; 7:1048-1054.

3. Neumann ID. Brain oxytocin: A key regulator of emotional and social behaviors in both females and males. NeuroImage. 2008; 20:858-865.

4. Kirsch P, Esslinger C, Chen Q, et al. Oxytocin modulates neural circuitry for social cognition and fear in humans. Journal of Neuroscience. 2005; 25:11489-11493.

5. Labuschagne I, Phan KL, Wood A, et al. Oxytocin attenuates amygdala reactivity to fear in generalized social anxiety disorder. Neuropsychopharmacology. 2010; 35:2403-2413.

6. Kosfeld M, Heinrichs M, Zak PJ, Fischbacher U, Fehr E. Oxytocin increases trust in humans. Nature. 2005; 435:673-676.

7. Baron-Cohen S, Wheelwright S, Hill J, Raste Y, Plumb I. The “Reading the Mind in the Eyes” Test Revised Version: A study with normal adults, and adults with Asperger Syndrome or high-functioning autism. Journal of Child Psychology and Psychiatry. 2001; 42:241-251.

8. Domes G, Heinrichs M, Michel A. Oxytocin improves “mind-reading” in humans. Biological Psychiatry. 2007; 61:731-733.

9. Heinrichs M, Baumgartner T, Kirschbaum C, Ehlert U. Social support and oxytocin interact to suppress cortisol and subjective responses to psychosocial stress. Biological Psychiatry. 2003; 54:1389-1398.

10. Strathearn L, Fonagy P, Amico J, Montague PR. Adult attachment predicts maternal brain and oxytocin response to infant cues. Neuropsychopharmacology. 2009:1-12.

11. Panksepp J. Brain emotional systems and qualities of mental life: From animal models of affect to implications for psychotherapeutics. In: Fosha D, Siegal DJ, Solomon MF, eds. The healing power of emotion: Affective neuroscience, development and clinical practice. New York: Norton; 2009:1-26.

12. Taylor SE, Saphire-Bernstein S, Seeman TE. Are plasma oxytocin in women and plasma vasopressin in men biomarkers of distressed pair-bond relationships? Psychological Science. 2010;21:3-7.

13. Bartz JA, Zaki J, Ochsner KN, Bolger N, Kolevzon A, Ludwig N. Effects of oxytocin on recollections of maternal care and closeness. PNAS. 2010; 107:21371-21375.

14. Bartz JA, Simeon D, Hamilton H, et al. Oxytocin can hinder trust and cooperation in borderline personality disorder. Social Cognitive and Affective Neuroscience. 2010; November:1-8.

Being a fan of attachment theory and research, I had one of those—unfortunately rare—“ah-ha” moments when I came across a phrase about self-love in New Zealand philosopher Christine Swanton’s fine book, Virtue Ethics. Swanton made the case that self-love is a virtue that entails bonding with yourself.

“Bonding,” I thought, “That’s attachment.”

Accordingly, we might think of self-love as embedded in an attachment relationship, more specifically, a secure attachment relationship with yourself. We know from extensive attachment research that infants become securely attached with caregivers who are sensitively responsive, that is, emotionally attuned to the infant’s signals (e.g., cries) and appropriately responsive to them (e.g., relieving sources of distress and being comforting).

Safe haven

In essence, a secure attachment relationship provides you with a sense of safety and a feeling of security when you most need it, that is, when you’re feeling threatened or distressed. This comforting experience is called the “safe haven” of attachment. At the same time, having this safe haven provides you with a “secure base” for exploration: you can go forth in the world, confident that you can return to your secure base when you run into trouble. Think of the toddler on the playground who explores confidently as long as the caregiver is within view. Thus, with secure attachment, you are more self-reliant.

Ideal relationships

Sometimes I like to start patient education groups by asking, “What are the characteristics of an ideal relationship?” Invariably, we come up with a list that is characteristic of attachment security: trust, caring, compassion, empathy, acceptance, dependability and so forth. Then I ask patients to imagine, “What if you had this kind of relationship with yourself?” I refer confidently to the idea of a relationship with oneself, because all of us engage in internal dialog or conversation (and you might talk out loud to yourself sometimes too). This internal conversation can be highly emotional, sometimes painfully so. That is, you might criticize, attack, demean, discourage, or berate yourself, including cussing at yourself. To put it bluntly, this is akin to having an emotionally abusive relationship with yourself—potentially modeled on earlier relationships of a similar nature.

Having vs. doing

Alternatively, if you have a secure attachment relationship with yourself, your internal dialog will be more loving. That is, you will be sensitively responsive to your distress, in your own mind. You will be attentive to your needs—empathic, compassionate and understanding. You will encourage yourself, expressing confidence in yourself. Thus I think of self-esteem and self-worth not as something you have but rather as something you do (or fail to do): you esteem and value yourself, in dialog, in your mind (or fail to do so).

In his book The Search for the Secure Base, our colleague, British psychoanalyst Jeremy Holmes, calls this secure attachment relationship with yourself the internal secure base, which is a source of inner comfort and support. In their book Attachment in Adulthood: Structure, Dynamics and Change, Mario Mikulincer and Phillip Shaver have demonstrated the sheer power of the internal secure base in experimental research. They have found that merely thinking about persons to whom you are securely attached, or remembering comforting interactions with them, can evoke a feeling of security that provides a buffer from distress. Thus bringing to mind these relationship experiences can serve a function similar to being with a person to whom you are securely attached. Of course, there is no substitute for the real thing—face to face contact and comforting touch—especially when you are in dire need.

New tricks for old dogs

The basic principle is simple: for better or for worse, you learn to do for yourself, in your own mind, what others have done for you. I often hear, “You can’t love others until you love yourself.” How do you learn to love yourself? By being loved. All of us are inclined to repeat what we have learned in previous relationships. Just as you can create an internal secure base, you can develop something akin to an internal insecure base as a result of previous learning. In that case, you might be punitive or neglectful toward yourself.

But attachment research is hopeful in showing that the quality of attachment can change for the better—from insecure to secure—on the basis of new learning. Such new learning will be founded on establishing relationships with persons who are trustworthy, accepting, caring, empathic and so forth—in sum, sensitively responsive to your feelings and needs. But attachment in adulthood is a two-way street: to be sensitively responsive, the person to whom you are attached will need to be securely attached and will need sensitive responsiveness from others—including you.

The field of psychotherapy suffers from acronymania: a proliferating plague of acronyms. Your psychotherapy brand will not be taken seriously if you don’t have a good acronym for it, preferably three letters, although you can get by with four or two. A short list: CBT, DBT, TFP, DIT, CPP, TPP, SIT, ERP, IPT, PCT, CFP, EFT, MBT, RLX, EMDR, ADEP and PE. Ideally, your therapy will qualify as an EBT or EST (evidence-based or empirically-supported treatment), that is, a treatment of experimentally-proven effectiveness that comes with a manual instructing the therapist on how it’s to be conducted.

More acronyms, please

Of course, we also have acronyms for psychiatric conditions: MDD, OCD, PTSD, BPD and so on. The crowning glory is having an EST for a particular condition: CBT for MDD, ERP for OCD, PE for PTSD and MBT for BPD (translation: cognitive-behavior therapy for major depressive disorder, exposure and response prevention for obsessive-compulsive disorder, prolonged exposure for posttraumatic stress disorder and mentalization-based treatment for borderline personality disorder, respectively).

We are truly blessed that clinician-researchers have developed all these ESTs for various psychiatric disorders. We need these specialized treatments for specific disorders and symptoms. Yet there are two problems with this state of affairs. First, to be fully competent in treating a range of psychiatric disorders, the therapist would need to learn 150+ treatment manuals—a daunting task. Second, many patients who seek treatment have a number of different disorders and problems at the same time (e.g., depression, anxiety, alcohol abuse, an eating disorder and personality disturbance).

Do we send such patients to several psychotherapists, as we might send patients to several medical specialists? Does the same psychotherapist administer several treatments sequentially, one after the other, or even concurrently?

Common factors

The problem I am addressing is not unique to psychiatry or even general medicine. We live in a world of increasing specialization such that individuals can hardly even keep up with the knowledge in their own field of endeavor. In the field of psychotherapy, there has been, in response to ever-increasing specialization, a countervailing movement for decades: the emphasis on “common factors” that account for the effectiveness of the therapy, regardless of the therapist’s specific technique or the brand name of the therapy. There is solid research support for this focus on common factors: it is extremely difficult to demonstrate that any good type of therapy is more effective than any other.

For example, we know that a positive therapeutic alliance—a trusting relationship in which the patient and therapist are working together toward common goals—is a major contributor to the effectiveness of therapy. Another important common factor is the therapist’s empathy. Recently, we have been advocating another common factor based on attachment theory and research: mentalizing, that is, an open-minded or mindful attentiveness to mental states such as thoughts, feelings and needs in oneself and others. It is a truism that psychotherapy requires interest in what is going on in the mind—and a meeting of minds. We use our colleague, Peter Fonagy’s, phrase for this process: holding mind in mind. We describe the ubiquitous role of mentalizing in relationships—including psychotherapy relationships—in our book, Mentalizing in Clinical Practice.

New psychotherapy brand

I am more concerned with common factors than specific techniques; I aspire to mentalize and help my patients to do so with me; and, not denying my competitive response to social pressure, I feel a need for a catchy acronym.

Hence, after more than four decades of practicing psychotherapy, I have decided on my own brand of psychotherapy: POT, Plain Old Therapy.

A patient once asked me at the beginning of our first session, “What kind of therapy do you practice? Talk Therapy?” I replied, “Yes, Talk Therapy, that’s what I do.” But I like POT better than TT.

To the extent that psychotherapists are returning to a common core of effective elements, the psychotherapy field might be going to POT. For many patients whose symptoms are multifaceted and rooted in problems with self and others, POT is in order. I acknowledge that POT is not optimal for treating patients with specific disorders for which effective specialized treatments are available. But even these specialized treatments, well delivered, must be laced with POT.

In his popular book, A Secure Base, John Bowlby, the psychiatrist and psychoanalyst who pioneered attachment theory, stated that the psychotherapist’s role is

“to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.”

In a trauma education group, I once remarked, “the mind can be a scary place.” A young woman in the group spontaneously replied, “Yes—and you wouldn’t want to go in there alone!” She thus epitomized Bowlby, and I have never heard such a trenchant characterization of psychotherapy since. This is POT, as I endeavor to practice it.

Dr. Allen is a co-author of this book on mentalizing.

I introduced the technical term “excrementalizing” in our book, Mentalizing in Clinical Practice. We start with the slightly less technical term “mentalizing,” which refers to the natural human ability to interpret behavior in relation to mental states: desires, emotions, beliefs and the like. If you were sitting and talking with a friend, and your friend suddenly leapt out of the chair and ran out of the room, you couldn’t help mentalizing: you’d try to figure out why your friend behaved in such an unexpected way. Panic attack? Forgot something vital and urgent? Had to go to the bathroom?

In short, mentalizing involves paying attention to thoughts and feelings in yourself and others. Mentalizing includes empathy, namely, awareness of others’ mental states. But mentalizing also includes awareness of your own mental states, in effect, empathy for yourself. We use some handy shorthand phrases for mentalizing: holding mind in mind, or being mindful of mind.

Mentalizing and attachment

We learn to mentalize in the first years of life, and we learn best in the context of secure attachment relationships, through which we can express feelings and desires with confidence that they will be well received and understood by those who care for us. Intuitively, infants will seek comfort from caregivers whom they sense have their mind (feelings) in mind.

Throughout life, mentalizing fosters secure attachments, that is, emotionally close relationships that provide a feeling of safety and security. Plainly, mentalizing makes for good communication in relationships. We advocate a mindful, “mentalizing stance,” namely, an inquisitive, curious, and open-minded interest in the experience of others and oneself. Mentalizing in this mindful way makes for a good relationship with oneself as well as with others.

When mentalizing breaks down

Mentalizing can go awry in three basic ways:

1. We can fail to do it, for example, ignoring the impact of our actions on others or acting without self-awareness in the midst of an emotionally aroused state—drinking without thinking;
2. We can misuse mentalizing to exploit, torment or mislead others; and
3. Finally, we have excrementalizing, our technical term for distorted mentalizing. Here’s a definition: mentalizing but doing a crappy job of it.

Mentalizing at the movies

Sideways, starring Paul Giamatti

Now to the back story. My wife and I took our daughter, Yvonne, to see the movie Sideways. Yvonne is a speech and language pathologist who works with children with autism, and she has been privy to mentalizing for many years. We were captivated by a scene in Sideways in which a main character, Miles (Paul Giamatti) was lamenting his fate: his agent could not find a publisher for his book and gave up on him.

Sitting under a bridge and looking out toward the water with his cohort, he proclaimed, “Half my life is over and I have nothing to show for it—Nothing!” Then he talked about his insignificance: “I’m a thumbprint on the window of a skyscraper.” Here’s the line that grabbed us:

“I’m a smudge of excrement on a tissue surging out to sea with a million tons of raw sewage!”

Reflecting on this line on our drive home, Yvonne exclaimed: “He was excrementalizing!”

Such self-deprecating depressive rumination is a common example of excrementalizing. Paranoid interpretation of others’ behavior is another. But excrementalizing isn’t a sign of disturbance; we all are inclined to misinterpret or misconstrue our own and others’ behavior sometimes, if not much of the time. We need to check out our perceptions with others and talk through our thoughts and feelings to mentalize with some reasonable degree of accuracy. Excrementalizing is a handy concept that can promote self-awareness: being alert to the possibility that you are excrementalizing is, in fact, good mentalizing. Ironic, isn’t it?

1974 Immanuel Kant stamp

I am partial to big ideas, general concepts that keep us properly oriented. And I’m more concerned with what’s important than what’s new. So I was captivated by a chapter entitled “Love and Respect” in New Zealand philosopher Christine Swanton’s book Virtue Ethics. Swanton draws from the eighteenth-century German philosopher Immanuel Kant, who declared that love and respect are the two “great moral forces.” What could be more important than great moral forces?

Love and respect

Kant made an intriguing contrast:  love entails coming close, whereas respect entails keeping one’s distance. Consistent with our ordinary sense of the word, Swanton elaborates loving as involving concern for the welfare of the beloved, desire to be together, expression of affection, sharing of experience and compassion. She also includes novelist and philosopher Iris Murdoch’s view of love as requiring attentiveness to the reality of the other person, undistorted by one’s own needs and emotions.

At first, I found equating respect with keeping distance to be somewhat jarring but, as Kant saw clearly, respect is an essential counterpart to love.

Kant framed love and respect as opposing forces that keep one another in check; Swanton asserted that love and respect maintain equilibrium in relationships.

Respect entails keeping distance in the sense of appreciating separateness, giving the other person space and granting autonomy. We should not lose sight of Swanton’s claim that the moral force of respect encompasses self-respect, which is consistent with setting limits and maintaining boundaries in relationships. Failures of respect include wounding and controlling others, which are intrusive and thereby violate respect.

Love, respect and attachment

These two moral themes of love and respect are pervasive in the psychological literature, for example, in the recognition that development entails striking a balance between connection and separateness, or relatedness and autonomy. Attachment theory, as developed by psychoanalyst John Bowlby and psychologist Mary Ainsworth, elegantly frames this balance in terms of two pillars of security:  a safe haven and secure base. Think of the toddler with his mother on the playground:  with her enthusiastic encouragement, he explores confidently, as long as he sees she is still there when he checks back periodically. If he falls down or sees a frightening dog, he wants to make contact with his emotionally responsive mother. Having made contact, then feeling safe and reassured, he can return with her encouragement to exploration and play, confident that she will be there when needed.

In sum, parents of the securely attached child encourage closeness in offering a safe haven in the face of danger, and they support distance in providing a secure base for exploration. A failure to provide a balance of safe haven and secure base experience contributes to insecure attachment, which takes the forms of needing to stay too close (anxious attachment) or maintaining too much distance (avoidant attachment).

Bowlby and Ainsworth were emphatic about our lifelong need for secure attachment:  all of us, toddlers at heart, need a safe haven and secure base “from the cradle to the grave,” as they put it.

We move back and forth between closeness and distance and, ideally, as attachment figures—parents, romantic partners, caregivers—we balance love with respect in moving back and forth between providing comfort and encouraging autonomous exploration and the self-confidence that goes with it. As our colleague, psychoanalyst Peter Fonagy, has taught, we maintain this equilibrium in attachment relationships by means of our natural human capacity to mentalize, that is, to be aware of thoughts and feelings in others and ourselves. On the one hand, mentalizing enables us to feel connected through empathy; on the other hand, mentalizing enables us to be aware of the separateness of our mind from the mind of others, that is, to recognize the uniqueness of each person’s perspective.

Love, respect and stigma

Pertinent to the general theme of this blog, we should note that love and respect are antithetical to stigma, which is a manifestation of contempt. As Swanton states, contempt shows a failure to come close insofar as it maintains a barrier, for example, in cold indifference. Yet she also points out that contempt entails a failure of respect in being a form of psychological wounding. In this respect, contempt shows failure to keep distance; it can be intrusive, for example, in taunting, bullying or talking down to the person held in contempt.

As mental health professionals, as attachment figures, as humans, we navigate in a moral space, balancing love and respect. To navigate this space adroitly requires judgment, common sense, wisdom and—technically speaking—mentalizing. We have much philosophy and psychological science to guide us, but navigating this elastic space between closeness and distance on a moment-to-moment basis is an art and, like any other art, we will not always find it easy to do well.