Attachment and loss: Matters of life and death

Alan Eppel

Posted with permission from New Therapist issue no.84 March-April 2013.

Love and Loss

The interplay of love and loss is the central dynamic in the human story. The longing for love and the pain of its loss are the most deeply felt of human emotions. This should not surprise us. The drive to attach to another is fundamental and primary in human nature. It is, after all, a matter of life and death for, without attachment, the human infant faces the prospect of isolation, exposure, starvation and death.

Over the course of geologic time, mammals have evolved a neurobiological program to bring infant and mother into proximity with one another. This mother-infant proximity system, known as attachment, is inborn. Reciprocally, the mother is genetically equipped with emotional systems to provide care-giving and nurturing.

The drive to attach stays with us throughout life. It determines the nature of our relationships. The subjective experience of feeling positively attached to another may be seen to constitute a large part of what we refer to colloquially as “love”. The converse state is separation, which is accompanied by sadness and despair.

More than half a century after John Bowlby’s radical transformation of the object-relations paradigm through the lens of attachment theory, we have come to recognize the enormous importance of his thinking as a model for the practice of dynamic and emotion focused psychotherapies. Many of Bowlby’s key concepts had their precursors in the work of his colleagues of the object-relations school in England. Fairbairn’s fundamental principle that the ego is “object-seeking” is directly analogous to the attachment drive. Michael Balint’s “primary object love” also identifies this universal human striving. Bowlby translated these psychoanalytic metaphors into the language and science of ethology [the science of animal behaviour].

The Attachment System

The attachment system is a reciprocal interacting program between mother and infant. There are three overarching components of attachment:

  • proximity- seeking;
  • separation distress
  • secure base.

The infant has in-built circuitry to seek closeness to the primary attachment figure and to experience separation distress when the mother is not close by. The mother has corresponding programming to respond to the cries of the distressed infant.

Jaak Panksepp (1998) has elucidated the underlying neurobiological mechanisms involved in the attachment system. He describes the social bonding and separation distress system as one of seven core emotional systems that have their origins in the sub-cortical areas in the brains of mammals. He has termed the maternal system the “CARE/Nurturance system” and separation distress as the “PANIC”or GRIEF/DISTRESS” system (Panksepp, 2009).

Secure attachment develops when the mother is responsive and attuned to her infant’s needs for affection, touch, food, and removal of discomfort. Attunment refers to the mutually empathic interaction between mother and infant that is facilitated by face-to-face interaction, smiling, eye gaze, skin-to-skin contact, touch and rhythmic speech.

When close to the mother, the infant experiences positive feelings of satiety, pleasure, and feelings of inner goodness. When the mother or other primary attachment figure is able to consistently meet the infant’s need, this sense of inner goodness becomes the foundation for healthy identity development.

The infant’s emotional state is determined to a large extent by the proximity and responsiveness of the mother. Alan Sroufe (1996) has captured this in the idea that attachment is the ”dyadic regulation of emotion”. The dyadic relationship can soothe distress and amplify positive emotions of joy and exhilaration or, conversely, exacerbate states of distress and discomfort.

Schore (2001) has postulated that the quality of attachment relationships is particularly critical in the first three years of life and has a major impact on brain development, particularly with regard to the right hemisphere and the limbic system.

It is not necessary that the primary caregiver meets the infant’s needs all of the time. In fact a 100% response rate would not be optimal for development, as the infant needs to develop some tolerance to being alone. Winnicott referred to “good-enough mothering”, which is the amount of sensitivity and responsiveness that ensures healthy psychological development of thechild.

Edward Tronick (1998) has furthered our understanding of this by identifying three types of mother baby interaction:

The first of these is coordinated interaction, when mother and baby are engaged, and behaviour and affect are responsive and matching. This is associated with positive emotion in the infant.

Secondly, he identifies a miscoordinated interaction – a mismatch or lack of attunement. When there is a misalignment, the infant’s needs are not then met, resulting in the experience of the pain of separation, fear, discomfort, and inner feelings of badness. If misattunement is too frequent, the child grows up with insecure attachment, an inner sense of badness and unlovableness that forms the basis of his or her personality. However a certain amount of miscoordination may be required for the infant to be able to differentiate himself as separate from the mother. [Cf. Winnicott, 1965].

Thirdly, Tronick speaks of “repair”, the movement from a miscoordinated state back to a coordinated state, when mother and infant again interact in a mutually resonant way. This may lead to soothing and elimination of disturbing emotions and the return of positive feelings and sensations.

The infant’s repeated experience of repair leads to a positive inner sense of self, an expectation that things can be repaired. Repair of empathic misattunement facilitates secure attachment. Repair may also promote the acquisition of the capacity to endure deprivation and hardship—that is, the development of psychological resilience.

The Attachment system is an emotional operating system that is comprised of two aspects: firstly the behavioural or action components and secondly the inner feeling states that trigger and accompany these.

When the infant is apart from the mother he experiences the feeling states of sadness or depression, which lead to various behaviours, such as crying, searching and motor agitation. In response the mother experiences the feelings of concern and the desire to take care of the baby.

In the infant, the feeling that corresponds to secure attachment is the feeling of being loved. For the mother, the reciprocal inner state is the feeling of loving. Dopamine and oxytocin are two brain chemicals that are intricately involved in the control and experience of attachment and love (Panksepp 1998, p.252).

When the maternal environment is often misattuned and unresponsive, the infant experiences too much separation, with the accompanying affects of sadness, grief or depression. A child in this situation may grow up with a sense of being unloved and unlovable.

Physical and sexual abuse by caregivers are two of the most extreme forms of failed attachment. Abused children grow up with extreme insecurity and mistrust in relationships. Instead of healthy emotion regulation via the attachment dyad these children experience the terror and extreme psychological pain of abuse. They grow up with the inability to self-soothe and modulate their emotions. They display marked affective instability or, in Marsha Linehan’s terms, severe emotion dysregulation (Linehan, 1993).

Children with profoundly disturbed attachment relationships develop feelings of intense aloneness. Their adult attachments are insecure and are often characterised by avoidance or anxious preoccupation. Such adult individuals may attract diagnoses of complex posttraumatic stress disorder and/or borderline personality disorder.

A child growing up in a non-loving environment may be forced to suppress his true feelings. This often results from the need to accommodate to a demanding, abusive parent. The child is forced to suppress his or her authentic emotions and thoughts. This leads to the emergence of a false self (Winnicott, 1965).

Separation and loss

Separation is the converse of attachment; sorrow is the converse of love. The intensity of sorrow is proportional to the intensity of the attachment bond and its felt component, love.

The attachment system is a survival system. It follows that loss of attachment or the threat of loss of the attachment object leads to fear. Freud put it well:

“We are never so defenseless against suffering as when we love, never so forlornly unhappy as when we have lost our love object or its love” (Freud 1930a, p.82).

Separation, the loss of attachment, is the primal source of anxiety. The fear of separation and the fear of death are at various points in the life cycle inextricably bound. Death is the ultimate separation. Death is the final loss of attachment ties.

Erich Fromm recognized the significance of man’s essential separation and isolation:

“The awareness of his aloneness and separateness, of his helplessness before the forces of nature and of society, all this makes his separate disunited existence an unbearable prison. The experience of separateness arouses anxiety; it is indeed the source of all anxiety.” (Fromm, 1956, p.7)

Infants facing loss respond with protest and attempts to recover the mother (Bowlby 1980 p.9). the infant becomes distressed, cries, exhibits motor agitation and searches the environment for his mother. The infant has an intense longing for the mother but if she does not return the infant loses hope, becomes inactiveand withdraws. He experiences “unutterable misery” and despair.(Bowlby 1980). Above all there is a feeling of extreme abandonment and aloneness. Adults confronted with separation or loss through death experience the same emotions: Protest , despair, withdrawal, feelings of aloneness. This can be so intense that that the sufferer may contemplate suicide. Attachment is a life preserving system. Loss of attachment is life threatening.

In the protest phase anger can be expressed verbally or violently. Men with extremes of preoccupied attachment are possessive and abusive of the love object. They may exhibit extreme rage after separation and pose a risk of homicide directed against the spouse and/or new mate: “if I can’t have you no one can”.  This is one scenario of homicide-suicide.

Our sense of self and identity evolve through our attachment relationships in childhood. Patients with insecure attachment such as those with borderline personality disorder, often describe feeling “invisible”, unseen. Loss or abandonment may lead to suicide. It is too unbearable to be alone.
Bereavement often entails a loss of identity, expressed by those widowed after long marriages. Despair and loss of the will to live may follow. Without the other, the “Thou” in the “I-Thou” relationship ( Buber 1970), there is no “I”.

Implications for psychotherapy

Love and loss are central in life and constitute recurring themes in psychotherapy. Psychotherapy is an attempt to reach across the space between attachment and loss in an effort to heal.

Bowlby recognized that his theory had applications to psychotherapy (Bowlby 1977): foremost among these were to provide the patient with a secure base from which to explore relationships, and to help the patient to appreciate how his current difficulties may be understood in terms of his attachment relationships.

Attachment theory has become an essential component in many psychotherapies. It has been extended into psychoanalytic practice by a number of contemporary therapists an researchers (Fonagy 2001).

Accelerated Experiential Dynamic Psychotherapy(AEDP), developed by New York Psychologist Diana Fosha, explicitly applies concepts from attachment theory and research. AEDP therapy begins by establishing safety, a secure base to counteract the patient’s feelings of aloneness.

Fosha argues that interpretation and insight do not lead to change but, rather, it is the experience of previously “unbearable affect” in the present moment within the securely attached dyadic relationship with the therapist that is transformative. This type of psychotherapy involves us reaching across the divide that separates the therapist from the patient—reaching across to attach and to mitigate the pains of loss and separation.

Fosha integrates the ideas of many pioneer’s in the field. There is a strong influence of Winnicott in some of her overarching views of the psychotherapeutic relationship. She trained with Habib Davanloo, who had developed an intensive form of short-term dynamic psychotherapy. Davanloo’s method involves breaking through to unconscious material by forcefully challenging defenses. Fosha crafted a very different approach to get past defenses to “core affects”. Adopting the attachment paradigm, rather than confrontation, Fosha employs empathic attunement. This requires moment-to-moment tracking and paying exquisite attention to minute signs of affective shift: body posture; facial expression; the slightest hint of a tear or a smile.

Fosha has also incorporated technical aspects from Leslie Greenberg’s Emotion Focused Therapy, David Malan’s Brief Psychotherapy, and Michael Alpert’s Accelerated Empathic Therapy, among others. AEDP is not exclusionary and integrates many components from emerging psychotherapies. Conversely many of its therapeutic techniques can be incorporated into other approaches.

AEDP is accelerated because moment-to-moment tracking and explicit empathy lead to rapid access to core affects and associated memories. It is experiential because the focus is on the experience of emotion in the present moment and staying with and processing it. It is dynamic in its use of defense work and concepts of self-other representations.

Fosha (2000) identifies three fluid states in the course of the psychotherapeutic interview:

In state one, when patients present, they are in distress. They display anxiety, disturbing symptoms and defensive operations. Distress may be the result of the failure of the defenses and be manifested in dysregulated affects or inhibiting affects, such as anxiety or shame. Defenses block access to core affect and lead to maladaptive behaviours. Several processes are used at this point: moment-to­moment tracking; dyadic regulation of affect, which is facilitated by the therapist responding in matching tone and rhythm; the expression of empathy, compassion, warmth and appreciation; and selective therapist disclosure of the positive impact the patient has on the therapist. This facilitates the patient “dropping down” to state two.

In state two the patient is in touch with core affects and experiences deep visceral emotion. Core affects include grief, sadness, anger, rage, fear, joy and excitement. Transformation to state two is analogous to Davanloo’s concept of “unlocking the unconscious” (Davanloo 1990). In state two, previously inaccessible feelings, thoughts and memories emerge.The therapist helps the patient to stay with these emotions by means of empathy, validation and dyadic regulation of affect. Painful core affects are connected with trauma, loss and disappointment.

State three is characterised by the emergence of a different set of affects: the healing affects of gratitude, tenderness and feeling moved; the mastery affects of pride and joy. The therapeutic intervention at this stage consists of metatherapeutic processing, a powerful intervention that can be incorporated into other dynamic methods of psychotherapy. Metaprocessing consists of patient and therapist reflecting together on the patient’s experience of the interaction with the therapist. This promotes a deepening of the affective experience and processing by the “cognitive” left brain.  Metaprocessing also allows for repair of empathic misattunements, which serves to powerfully deepen the therapeutic relationship and ideally will lead to state four, the core state. The core state is an experience of openness and connection; feelings of vitality and authenticity. This can be viewed as making contact with the “true self” (Winnicott 1965b).

At this point in the therapeutic process the patient and therapist feel an authentic sense of connection: the true self in relation with the true other. There is a felt sense of deep contact with one’s true inner experience, a sense of authenticity, calmness, clarity and self-compassion. Martin Buber (1961) describes the true encounter as occurring fully in a spaceless and timeless present, between one whole human being and another. The essence of humanity is defined by this dialogue, the true encounter, where deep connects with deep.


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