After almost three decades working as a psychoanalytic psychotherapist, I decided two years ago to plan my retirement from private practice. I found that as I started to mull over the idea of an end to an important era of my life, my mind started to focus on what aspects of my thousands of hours of engaging in therapy have brought the most satisfaction, and constituted the achievements of which I am particularly proud.
I have specialised in the past twenty years on working with clients who have both needed and wanted to engage in long-term therapy. My definition of “long-term therapy” includes those clients who have persevered in the psychotherapeutic process for at least five years; possibly for a lot longer. I have for many years been fascinated with an elucidation of the motivations that underlie such individuals contentedly settling into long-term therapy. As I am sure you appreciate, such a commitment requires a huge investment in terms of trust, time, money and psychic energy. I have wondered what makes some of our clients commit to therapy in this manner, whilst others who present in psychotherapy or counselling find it to be wholly satisfying to engage in short-term counselling? This is not to imply that either choice involves a deficit comparison in relation to the other.
When I first trained as a counsellor from 1989 to 1992, I was taught an eclectic model of therapy. However, even then I found that the theory which resonated most with my underlying metatheoretical assumptions to be that of attachment theory. Bowlby stressed the importance of environmental influence, and felt it to be central in an individual’s life rather than the effects of intrapsychic conflict. It is basically because of his move away from the primacy of intrapsychic conflict to environmental failure that he became marginalised within the psychoanalytic community.
Despite this negativity, his ideas were well-received by government during the post-war era, especially perhaps because it was a time of many individuals suffering from abandonment, loss and separation. For example, his paper and accompanying film (A Two-Year Old Goes to Hospital), produced along with James Robertson, have revolutionised the way in which parents are nowadays welcomed to accompany and remain with their children when they are hospitalised. Similarly, his 1951 paper which was specifically commissioned by the World Health Organisation (WHO), has radically changed the attitudes to institutional care provided by children’s homes and day nurseries. As a consequence, enforced separation of children from their parents tends to be avoided if at all possible nowadays. Nevertheless, many psychoanalytic therapists disagreed with Bowlby over his belief in the primacy of environmental failure, and still to this day his ideas are shunned in some circles.
My own belief centres on the notion that environmental failure – which can so easily lead to developmental deficit in the individual – is of radical import. However, unlike Bowlby, I also believe that intrapsychic conflict affects the individual significantly, as can be evidenced by reading my book on the effects on the individual who is not able to resolve his oedipal longings (The Oedipus Complex: Solutions or Resolutions?).
I have spoken briefly of the effects of separation, loss and/or abandonment on the growing child or adolescent. Almost always, extended periods of separation, or permanent loss of an attachment figure in the child’s world, results in the adult-child developing an insecure avoidant or insecure ambivalent attachment schema (to use Mary Ainsworth’s typology). Approximately one third of the populations suffer from one of these less than optimal attachment schemas. Those who suffer such a developmental deficit tend to have continuing difficulties in relationship issues which perpetuate in adulthood.
I believe that it is individuals who suffer severe developmental deficit who find long-term therapy the most efficacious and beneficial. It is my opinion that the best positive outcome is achieved for these individuals if they are provided with a healing, reparative experience by the therapist who enables the client to learn what it means to become securely attached. This necessitates that the therapist functions as “a secure base” (Bowlby, A Secure Base) for some extended period of time. The actual time frame necessary is in direct correlation with the extent of the damage caused by his experience of an insecure relationship between the client and his primary attachment figure. This is the meaning of “learned security” to which I refer in the sub-title of the book.
The concept of “learned security” has developed from research previously carried out by attachment theorists in the past decade on what is termed “earned security”. However, I differentiate “learned security” from “earned security” in a number of seminal ways. The term “earned security” is defined by Jeremy Holmes as applying to those individuals who have developed a reflexive function; other literature defines “earned secures” as those individuals who are able to parent their children in a secure manner despite their own difficult attachment experiences. The term “learned security” refers to the experiential, learned process that takes place when the therapist purposefully gives precedence in the consulting room to the provision of a secure base. The client then gradually learns a new, secure model of attachment, and is able to experience this new schema first of all within the therapeutic relationship and then becomes able to replicate this new schema in his relationships in the external world.
In the book, I seek to elucidate the conditions that the therapist must aim to provide in order to achieve this. Four extended case studies which evidence how I feel that this has been achieved in some therapeutic relationships provide practical examples to supplement the theory postulated. The adoption of this way of working has made my work as a therapist in the past two decades highly rewarding. It is so good to see the gradual metamorphosis of such individuals as their way of relating changes essentially to a secure manner of relating, both in the consulting room, and then in the external world.
Gradually, over a period of some years, I have developed a theoretical basis through which I ground my practice. Not surprisingly, central to this theory is Bowlby’s attachment theory. However, I have also been drawn to Stolorow, Brandchaft and Atwood’s intersubjective perspective, and to some of the ideas in Heinz Kohut’s self-psychology. By thinking in a dialectical manner, which necessitates thinking at a higher level of abstraction, I have found a unifying concept in order to integrate the three theories. I have used the concept that I have named: ‘intersubjective empathy’. Essentially, this necessitates that the therapist not only seeks to be consistently empathic, but also consciously engages the client in a process of co-construction and collaboration by checking out her empathic understanding in order to achieve the optimum level of empathic attunement. In this way, not only is a consistently empathic stance aimed for, but the therapist is also able to help the client to build a sense of narrative competence and cohesion. This, in my opinion, is also a sine qua non of the therapy experience.
I appreciate that some of you prefer to work in a short-term, more structured format. I strongly believe that there exists a continuum of ways of working, and I do not seek to put forward my way of working as the only legitimate way of providing therapeutic help. I hope that my book excites debate within the attachment fraternity and the wider therapy world. Part of my aim in life is to enhance the development of attachment theory in these years post-Bowlby.
Rhona M. Fear is a psychoanalytic psychotherapist practising in Worcestershire; she has specialised in working with clients in long-term therapy for the past twenty years since her six-year training in Psychoanalytic Psychotherapy. Initially, she trained as counsellor with Relate followed by attaining a Master’s degree in Counselling Studies at Keele University. Her first degree is in political science, and she maintains a keen interest in the political arena, having taken an active role in democratic government and in the founding of a number of Action Groups. She feels this provides balance in her life. She has published a number of papers and chapters on the Integration debate in the 1990s. Karnac published her first book, The Oedipus Complex: Solutions or Resolutions? in 2015.
Her latest book, Attachment Theory: Working Towards Learned Security, has recently been published by Karnac.