A Contemporary Relational Model: Integrating Attachment, Trauma and Neuroscience Research

Contemporary relational psychoanalysis emerged in the 1980s in the United States in an attempt to integrate interpersonal psychoanalysis with British object relations . A relational perspective emphasises the salience of early formative relationships on the development of personality and argues that the subject’s primary motivation is to seek relationships with others. By contrast, classical Freudian thinking views motivation in terms of intrapsychic drives of sexuality and aggression. Stephen Mitchell was a prominent figure in the development of relational psychoanalysis and is widely acknowledged as the founder of the relational tradition. He established the international journal, Psychoanalytic Dialogues, serving as its editor for the journal’s first decade. Following Mitchell’s untimely death in 2000, his work has been carried forward by a number of analysts and authors, including Lewis Aron, Jessica Benjamin, Philip Bromberg, Jody Davies, Emanuel Ghent, Adrienne Harris, Irwin Hoffman, Karen Maroda, Stuart Pizer, and Owen Renik.

Influenced by Fairbairn and Winnicott, Mitchell (1988) views psychopathology as characterised by constricted patterns of relatedness, with missing needs being regarded as a function of the interactive relational field. The patient’s problems are seen as stemming from their tie to familiar, but seriously constricted, relational patterns within which the self is experienced as false, fraudulent and inauthentic. In essence, therefore, the patient must choose between remaining attached to fantasised images which impart a subtle sense of safety and connection, and the possibility of attaining attachment to real others. For Mitchell (1988), then, the central process of treatment is the relinquishment of adaptive, defensive ties to constricted relational patterns as this will allow the patient to experience an openness to new and richer interpersonal relations. He views the affective interaction between the analyst and the patient as characterised by warmth and spontaneity. In this context, he stresses that the analyst must at times be prepared to take risks in order to connect with the patient in a real and authentic fashion. However, he suggests that the analyst should express their own subjectivity, not only through affective interaction but also through interpretative activity. By a combination of these means, the analyst becomes a particular sort of new object to the patient, different from early parental objects. Indeed, Mitchell (1988) concludes that the analytic relationship provides the opportunity for the patient to integrate intrapsychic and interpersonal experiences in a different, more enriching and adaptive fashion than was possible in their family of origin.

The following clinical vignette is from Mitchell’s book, Relationality: From Attachment Theory to Intersubjectivity (Mitchell, 2000). The brief vignette illustrates the founding principles of relational psychoanalysis: an integrative approach that explores the way in which early traumatic experience impacts on personality development and may create difficulties in forming and sustaining mutually rewarding and enriching relationships in later life.

Clinical Illustration

“George” is a man in his mid 20s whose wife had left him because he was “unexciting and distant”. The implications of George’s early sexually abusive relationship with his uncle, which apparently included oral and anal penetration, bondage and being dressed in female clothes, emerged during the course of his analysis with a female analyst. Aspects of these memories and associated dynamics were relived in the transference. This notwithstanding, George began to experiment with cross-dressing and to masturbate to sadomasochistic scenarios on the internet. He felt in the powerful grip of the traumatic memories, which he found both degrading and stimulating. The impulse to re-enact the abuse continued, despite his having developed an emotionally and sexually satisfying relationship with a woman. On saying good-bye to his girlfriend after an intimate weekend together, George was plagued with what he considered to be perverse, ego-alien impulses to engage in kinky masturbatory experiences and sadomasochistic activities instead of savouring the intimate pleasures of the weekend with his girlfriend.

As Mitchell (2000) points out, there are many possible ways of understanding this sequence. He details how Fairbairn might have thought about the case material from an object relations perspective. From this approach, Mitchell (2000) suggests that George’s internal object relation with his uncle “provided some of the most intense, passionate moments of his childhood. The excitement, the sense of drama, mystery, the forbidden that characterised his uncle’s experience also became George’s experience. George’s lustful impulses were not just vehicles to tie him to his uncle; they also were his uncle, and, through the boundary-permeable affective intensity of those moments, they were George himself, at his most excited, most adventurous, most alive” (p. 114, italics in original).

In thinking about George’s adhesive, seemingly addictive, attachment to the internalised relation to the abusive uncle, Mitchell (2000) cites van der Kolk’s (1994) neurobiological findings, observing that there is a physiology of attachment to early objects. Thus, George’s seemingly addictive propensity repeatedly to forge interpersonal relationships redolent of ties to early objects, even when these were traumatic and ego-dystonic, may reflect neurochemical as well as psychological derivatives. In the light of van der Kolk’s findings, Mitchell (2000) concludes that: “Early experiences are addictive, not just because of their psychological salience but also because of their neurochemical concomitants” (p. 115). Liotti’s (1999) motivational conceptual framework may be used to supplement Mitchell’s Fairbairnian and neurobiological understanding of the depicted sequence in the context of George’s early interpersonal experiences. Writing from an attachment and trauma perspective, Liotti (1999) argues that in order to avoid the painful, confusing experience of dissociation to which a contradictory, multiple self-representation developed in childhood is linked, the person may defensively inhibit the attachment motivational system by choosing, consciously or unconsciously, to activate a competing motivational system.

Liotti (1999) posits the existence of three basic motivational systems that compete with the attachment system: the agonistic, caregiving, and sexual systems. The activation of the agonistic motivational system leads the person to experience a high level of dysregulated rage and aggression, while the defensive activation of the caregiving system may lead to a form of compulsive, controlling caregiving behaviour. Alternatively, the person may choose to interact with other people on the basis of their sexual motivational system. The activation of this system creates “the basis for promiscuity and for the construction of any significant relationships according to the roles of seducer and the seduced" (p. 771). Liotti (1999) argues that the choice of the sexual motivational system is facilitated if the person has been sexually abused by an attachment figure. He contends that the three patterns of interpersonal relationships, based on the abnormal activation of the agonistic, caregiving, and sexual motivational systems, are selected in the service of avoiding painful attachment experiences. He suggests that these sub optimal systems may readily be observed in clinical practice in the treatment of people suffering from dissociative processes.

As Mitchell (2000) notes, “contemporary interpersonalists and theorists of intersubjectivity have contributed to our understanding of the ways in which the vicissitudes of early attachment experiences play themselves out in current relationships, including the transference-coutertransference relationship with the analyst” (p. 101). Employing an integrated model, in the context of George’s early traumatic experience of sexual abuse, the separation from his girlfriend after their pleasurable weekend together may be seen as a stressful event. For patients with a traumatic history such as George’s, even a relatively minor stressor may trigger a disproportionate, fearful reaction which cannot readily be terminated (Perry et al., 1995; Schore, 2001). George’s excessive reaction may itself be seen as indicating that implicitly encoded traumatic memories associated with his unresolved childhood trauma had been activated, leading to a concomitant release of stress-related neurochemicals. In consequence, the secure, coherent representational model that was available to George while he was in the reassuring and comforting presence of his girlfriend was overwhelmed, and the multiple, disorganised mental model in relation to the abusing uncle was activated in a context of separation and temporary loss. I have found that exploring with my patients in minute detail the relational context in which such shifts in representational models, object relations or self-states occur to be a crucial aspect of the therapeutic process. Such shifts and nuances of attachment phenomena (Slade, 2004) are motivated by dissociated memories and manifested as emotional procedures in the nonverbal, implicit/enactive domain of relating and experiencing (Bruschweiler-Stern et al., 2002, 2007; Lyons-Ruth et al., 1998; Stern et al., 1998a, 1998b).

As George lacked a coherent strategy to deal with the stress of separation, the experience was dissociated or defensively excluded from consciousness. Thus, George ‘chose’ to inhibit the attachment motivational system in order to avoid experiencing painful affect associated with his girlfriend leaving, and instead activated the sexual motivational system (Liotti, 1999). Being unable to reflect upon and organise this mildly stressful attachment-related event, it would seem that George experienced it in the mode of psychic equivalence (Fonagy et al., 2004). This mode of functioning reflects the difficulty that George has in differentiating inner reality from external reality in stressful interpersonal contexts. Thus, when left alone after the pleasurable weekend with his girlfriend, George was unable to mentalise the experience and so succumbed to the impulse to seek comfort and solace in masturbatory fantasies and sadomasochistic activities with strangers on the internet as a maladaptive form of affect regulation (Schore, 1994). Moreover, as Mitchell (2000) points out, George’s adhesive attachment to the internalised uncle, as manifested in repetitive re-enactments of the sexual abuse, would seem to be maintained by neurochemical as well as psychological derivatives.

Given this, I would argue that George’s addictive attachment is as much to a psychobiological state as to an actual person. In this sense, his relationship to the other predominantly serves as a vehicle to re-experience a familiar, albeit traumatic, state of mind. An intimate, emotionally meaningful relationship with a real other does not carry this valence for George and thus is unlikely to be sustained, as appears to have been the case in his marriage. The description of George as being “unexciting and distant” in the relationship with his wife would indicate that he had developed an avoidant/dismissing state of mind in respect of attachment, and therefore employs deactivating strategies and distancing procedures to regulate his discomfort with emotional intimacy. In terms of Ferenczi’s (1933) concept of identification with the aggressor, as an abused, helpless child, it is likely that George became oblivious of himself, passively gratifying the desires of his abusive uncle. In negating himself in this way, George was transformed into the image that his uncle had of him – as an object to be used and abused. Ferenczi’s (1933) theory may partly account for the passive aspects of George’s personality and behaviour. The more active part of George, in the form of physical and emotional withdrawal from others, may partly be understood by reference to Anna Freud’s (1993) later formulation of identification with the aggressor. In this instance, George may be seen as identifying with a caregiver who routinely turned away from him, leaving him too alone. In contrast to Ferenczi (1933), Anna Freud (1993) views identification with the aggressor as a defensive process whereby the individual transforms himself “from the person threatened into the person who makes the threat” (p. 113). For Anna Freud (1993), the change from the passive role to the active role is a means of assimilating “dissociated” traumatic experience which is turned into “an active assault on the outside world” (p. 116). As Frankel (2002) notes, both forms of identification with the aggressor may be in operation simultaneously, being used to adapt to a threatening external reality, as well as to cope with disturbing inner feelings that arise as a result of a threat to the self.

Mitchell (2000) does not provide any details of George’s developmental history, other than the sexual abuse by his uncle, as the main purpose of the vignette is to illustrate Fairbairn’s thinking in respect of impulses and guilt. It may, nevertheless, be accepted that this traumatic experience alone set George on a developmental trajectory characterised by anxiety and insecurity and a concomitant difficulty in sustaining an emotionally enriching intimate relationship. However, early trauma and abuse occur within an ongoing relational context. This being so, George’s attachment history and the characteristic intersubjective/attachment system within which he experienced the trauma may be as salient to his personality development and adult psychopathology as the abuse itself. In the absence of more details about the quality of George’s early and current relationships with his parents, ex-wife and girlfriend, as well as his discrete discourse style in interaction with his analyst, my conjecture from an attachment perspective, as set out above, must remain just that, conjecture. While not wanting to minimise the traumatic impact on George of the sexual abuse by his uncle, I would agree with Mitchell (2000) that we need to take account of the broader developmental picture, too, in terms of cumulative attachment trauma, in understanding the quality of our adult patients’ intersubjective relationships.

Clinical Implications of a Developmental Perspective

Mitchell’s (2000) case vignette of George illustrates the way in which implicit/procedural memory creates a bridge between early childhood experiences and psychopathology in adulthood. The case also shows how a neurobiological and developmental perspective may be integrated with a relational model in clinical work with adults. Indeed, writers such as Emde (1980), Hurry (1998) and Schore (1994) emphasise that developmental factors play a role in all analyses and are an important aspect of the therapeutic process. Moreover, that developmental work is rooted in the individual personalities of the patient and therapist, and in their spontaneous interactions. This being so, developmental work requires the therapist to bring their own emotions and subjectivity more explicitly into the therapeutic encounter, as advocated by Mitchell (1988). Indeed, Tähkä (1993) emphasises the therapist’s legitimate experience of parent-like feelings of pleasure and pain as part of an appropriate developmental relationship with the patient. However, it needs to be acknowledged that there is a heightened countertransferential risk in developmental work of the therapist using the patient variously as a source of narcissistic gratification, to relieve guilt, to overcome feelings of helplessness or to gratify their own infantile needs (Tähkä, 1993). Hurry (1998) stresses that these risks demand ongoing self-reflective monitoring of the countertransference.

The spontaneous features of developmental work also highlight the importance of the ‘fit’ or ‘match’ between patient and therapist. Indeed, Kantrowitz (1995), in her long term follow-up study on this very issue, found that patient-analyst match was the major factor relevant to successful outcome, a point also emphasised by Maroda (2010). Developmental aspects of the therapeutic relationship may also be seen as reflecting what is often referred to as the ‘real relationship’, as compared with the transference relationship. On discussing this clinical issue, Ogden (2004) observes that the quality of intimacy developed between therapist and patient will include feelings of camaraderie, playfulness, compassion, healthy flirtatiousness, charm, and enlivening humour. With regard to the latter, it is often overlooked that humour constitutes a shared, intersubjective experience that has a significant therapeutic benefit (Lemma, 2000).

Developmental studies suggest that the capacity for intersubjectivity develops in tandem with a subjective sense of self in the preverbal domain of intersubjective relatedness (Stern, 1985), and in the context of an ongoing attachment relationship. Findings indicate that the developmental achievement of mentalisation or reflective functioning is seriously compromised by attachment trauma. For the child who has been abused or, indeed, consistently negated, there may be a defensive avoidance of knowing the thoughts and feelings in the mind of the other. This is because the child, and later the adult, expects to discover therein a hostile, malevolent intent, and a reflection of the self as bad, shameful and, perhaps even worse, as not existing at all (Fonagy & Target, 1996; Fonagy et al., 2004; Fonagy 2008). In the light of these findings, understanding the adult patient’s traumatic experience from a developmental perspective is, I would argue, crucial to informing the therapeutic relationship and process of change, and to enhancing their mentalising capacity and sense of self-agency (Bateman & Fonagy, 2004; Diamond & Kernberg, 2008; Holmes, 2010; Knox, 1999, 2001, 2003; Renn, 2008a, 2008b, 2012).

In the service of enhancing self-reflexivity and intersubjectivity, Aron (1996) advocates asking patients to describe anything that they might have observed about the therapist, and to speculate or fantasise about what he or she might be thinking or feeling in relation to the patient. He argues that this form of openness and curiosity facilitates the patient’s perception of the analyst as a separate subject. However, in acknowledging the limitations of our own self-awareness, Aron (1996) points to the risk both of imposing our subjectivity onto the patient and of presuming to know whether or not we are “validating” or “confirming” our patients’ perceptions of us.

In my clinical experience, there are significant therapeutic gains to be made not only from inviting patients to think about what is in the therapist’s mind, as advocated by Aron (1996), but also from encouraging them to explore and appraise what is in the minds of the people they interact with in their everyday lives. I would suggest that this constitutes a more fully systemic way of working, as described by Wachtel (2008). So often patients seem confused about what is motivating the behaviour and actions of their nearest and dearest, and use the therapist in a rather passive way to try to give meaning to the intentions of others. By engaging the patient in an active process of mentalisation, linked to an exploration and elaboration of the emotions associated with any given interpersonal context, they may be helped to shift out of an habitual non reflective mode into an intersubjective state of being-and-relating which understands and takes account of the other person’s motivations and perspectives. As Aron (1996) points out, this intersubjective aspect of the therapeutic process may protect the patient from passively complying with, and submitting to, the therapist’s power and authority in a way that reprises Winnicott’s (1960) concept of the ‘false self’.

Benjamin (1995), however, questions to what extent any aspect of subjectivity may be privileged as the truer, authentic part in relation to which other parts are false or inauthentic. Influenced, nevertheless, by Winnicott (1949, 1960, 1971), she amplifies Mahler et al.’s (1985) theory of separation-individuation, stressing the role that aggression plays in the development of intersubjectivity. Benjamin (1995) argues that mutual recognition and intersubjective relatedness are not inevitable aspects of infant development, but rather are developmental achievements linked to the quality of the mother-infant relationship, which may either be oppressive and controlling or facilitating and liberating. The struggle for recognition brings forth aggression and thus separation. This fosters a symbolic space between mother and child. The mother’s task is to balance the constant tension between assertion of the self and recognition of the other. Benjamin (1995) sees this developmental process as the necessary basis for non-coercive intersubjectivity. Informed by developmental studies, she notes that relatedness is characterised not by continuous harmony, but by a continuous process of disruption and repair (Beebe & Lachmann, 1992). When the process of mutual recognition breaks down because of conflict in the mother-infant relationship, experience is organised predominantly intrapsychically rather than intersubjectively, the upshot of which is a struggle for power (Benjamin, 1995). Such unresolved developmental issues are likely to emerge in the transference/countertransference matrix.

Knowledge as an Aspect of Power

The asymmetry of power in the therapeutic relationship has been a concern of relational psychoanalysis since its inception. The paradigm shift from a classical model to a relational model emphasised concepts of mutual influence, discontinuity, multiplicity, and co-construction of subjective experience in clinical work. This shift changed the role of the therapist from an objective observer who is free from the patient’s direct influence, and who provides interpretations from a detached, neutral perspective, to a two-person process in which mutual influence is ubiquitous, and what the therapist knows is inevitably altered by their participation in the intersubjective field (Gabbard, 1996).

A relational/intersubjective perspective, then, recognises that there are two subjectivities in operation in the analytic enterprise, and emphasises the way in which the therapist initiates behaviours and affects, as well as reacting to what the patient does in the therapy (Natterson, 1991). Moreover, there is no singular truth to be revealed, rather the patient’s subjective experience and difficulties in living may be understood and co-constructed in a multiplicity of ways (Mitchell, 1993). However, as Aron (1996) and Benjamin (1992) respectively point out, an awareness of the way in which our own subjectivities and theoretical orientations influence and limit such multiple possibilities merely raise new problems of power, in terms of a tension between mutuality and asymmetry, as well as thorny questions about what the analyst knows and does not know.

In discussing “knowledge as power”, Benjamin (1992) cautions against idealising a stance of “not-knowing” in reaction to the old classical ideal of analytic certitude. Indeed, Winnicott (1974) contends that the therapist can hold up the patient’s progress “because of genuinely not knowing” (p. 177). He argues that the patient’s phenomenological experience of “primitive agonies” and concomitant “clinical fear” of a future breakdown is, in fact, the fear of a breakdown that has already happened, but which has “not yet been remembered” (ibid). He suggests that patients need to be told about this crucial aspect of their lived experience for which they have no memory.

In this context, Frankel (2006) acknowledges the reluctance in contemporary psychoanalytic circles to diagnose the patient out of fear that this kind of “knowing” may objectify the patient, thereby negating or obliterating their subjective experience. This notwithstanding, he argues that diagnosis is an idea that cannot easily be given up because people do have distinctive personality characteristics and limitations that endure over time. Moreover, he contends that no technique can eliminate the inherent power differential in the therapeutic relationship, or the therapist’s unconscious use of this relationship for good or for ill. In an attempt to overcome this dilemma and move away from a diagnostic medical model, Frankel (2002) proposes a relational model that includes the concept of diagnosis-of-the-moment: an interactive process that informs how the therapist responds moment-by-moment to the patient’s changing self-states and multiple ways of organising subjective experience. Similarly, Davies (2004) argues that in work with survivors of childhood sexual abuse, the therapist is required to make multiple shifting diagnoses in response both to the vicissitudes of the patient’s self-states and to the different roles that the therapist is drawn into enacting in the transference/countertransference matrix. In this overall context, it needs to be kept in mind that powerlessness is a key feature of developmental trauma, and that dissociation in reaction to trauma walls off access to self-experience and emotional connection with others (Bromberg, 1998).

Aron (1998) eschews diagnosis, emphasising, instead, that what the therapist knows is partly informed by his or her observations of the patient’s body, in terms of gesture, facial expression, and posture. This clinical stance is consonant with the recent discovery of the mirror neuron system (Gallese, 2009). Orbach (1995, 1999, 2004), too, highlights the use of the therapist’s body countertranference to register and understand the patient’s implicit affective states and communication of unconscious material. From a relational perspective, it is assumed that these processes are mutual, and that the patient will change the therapist as part of a continuous process of bi-directional or mutual influence in the intersubjective field (Aron, 1996). This conceptualisation of the therapeutic process is consonant with the findings of developmental studies (Beebe & Lachmann, 1992, 2002), and challenges the view of countertransference as a static, intermittent event occurring in reaction to the patient’s transference. Mutual influence, however, does not imply equal influence, in that the relationship can be mutual without being symmetrical (Aron, 1996). The therapist’s struggle to understand and recover from ‘mistakes’ and enactments without becoming defensive or inauthentic is seen as a central aspect of the therapeutic relationship leading to mutual recognition and change (Aron, 1996; Benjamin, 1995; Frankel, 2002; Mitchell, 2000). Again, this aspect of the therapeutic process is consonant with attachment research which shows that secure attachment is facilitated when ruptures to the parent-child attachment bond are repaired in a contingent and predictable way. It follows that the process of disruption and repair in clinical work with adults promotes a sense of felt security and thus the capacity to experience new information and relationship transformations in the implicit/enactive domain (Beebe et al., 2000; Lyons-Ruth et al., 1998).

We see, then, that relational psychoanalysis is in an ongoing process of integrating the empirical findings from attachment research and developmental studies. Mitchell (1988), however, strikes a note of caution, observing a certain tendency in developmental work to view the patient as an infantile self encapsulated in an adult body – the so-called ‘child within’ (Balint, 1968; Miller, 1991). He terms this tendency the ‘developmental tilt’. Here, adult relational needs are collapsed into infantile neediness stemming from unsatisfied developmental needs. From this perspective, psychopathology is variously perceived in terms of frozen development, unresolved regressive residues from early life, or infantile fixations, and the patient is portrayed as a passive, inactive victim of a depriving environment. This way of thinking may be seen in Balint’s (1968) formulation of the ‘basic fault’, which reflects the lack of care and nurturance available to the individual in early development. For Balint (1968), the therapeutic process should avoid conflict and facilitate a ‘benign regression’. By contrast, Mitchell (1988) suggests that casting the analytic enterprise as regressive seriously distorts the nature of the analytic experience by collapsing relational needs into the kinds of interaction characterised by the relationship between the small child and the mother. He argues that using the metaphor of the self as baby in such a concrete, reified fashion assumes that the clinical material reflects universal infantile needs, actual memory traces, and an underlying structural dimension to the patient’s experience.

Somewhat paradoxically, in his later writings Mitchell (1993) contends that in many respects the good enough caregiver-infant relationship constitutes the prototype of a therapeutic model in work with adults, and that the analytic process is redolent of the subtle intersubjective, communicative and regulatory processes that take place between mother and child. His change of emphasis may reflect more recent findings in the field of attachment and developmental studies. As we have seen, these show that the internal world develops through an active, mutual process of reciprocal influence, and that the mind is composed of self-other representational models developed in the context of interaction with others.

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