'Coming out’ as a psychotherapist can be stigmatising enough, but if you happen to be an attachment-based psychoanalytic psychotherapist, the recent media reports about the rise in the popularity of so-called ‘Attachment Parenting’ do not help. Reports about seven year-old children being breastfed and three year-olds being schlepped around in slings must have contributed to the fact that the word ‘attachment’ is met with many raised eye-brows. Attachment Parenting literature frequently references - and very quickly contradicts - Bowlby and his attachment theory, in the way that it is partly misinterpreted and accordingly implemented. Central to attachment parenting seem to be the 'Three Bs' – breastfeeding, babywearing and bedsharing, and parents are advised to practise these until the child decides to stop them, which often doesn’t happen until a child is half a teenager.

In his theory about attachment, which attachment-based psychotherapy is based on, Bowlby did state that emotionally sensitive and responsive childcare is vitally important for human beings and their development, especially in the first two years of life. By providing this, a caregiver regulates a baby’s emotions and gradually teaches him or her to be able to start doing this himself or herself. (First clue.) A caregiver should also provide this in a consistent manner, all of which is likely to lead to a secure attachment between infant and caregiver, which will simultaneously facilitate separation. Such care will provide a secure base that allows the child, on his or her own terms, to gradually start exploring the external world, knowing that there is a secure relationship / secure base with the caregiver, who can offer help or consolation should something go wrong during exploration. The secure base is so important because it facilitates exploration. (Second clue.)

Attachment parenting (as portrayed by the media), if it entails frequently carrying a child around, especially after two years of age, restricts the child’s opportunities to explore, to have his or her own experiences, and is likely to affect the child’s development. Separation is avoided, and Winnicott’s idea of a ‘facilitating environment’, characterised by the gradual, child-driven testing of boundaries, risk-taking, socialising, playful exploring and separating in a secure environment is largely being denied. Such a ‘facilitating environment’, encouraging exploration and play, is essential for the child to develop a creative, ‘true self’, as opposed to a false one. A lack of this can stifle development, emotionally and mentally, but also physically. Motoric skills are acquired by letting toddlers crawl, walk, run, climb and fall over. They are surprisingly good at slightly pushing the boundaries while generally keeping themselves quite safe, and can do amazingly difficult things if they are given the freedom to gradually build up these skills with a sense of self-agency from early on. Of course under a watchful, but not over-interfering, eye of the parents.

I doubt that continuously carrying your child around beyond, say, two, as well as making your child’s every wish your command, was the kind of good mothering Bowlby had in mind to ensure the development of secure attachment. The same applies to co-sleeping and homeschooling. Yes, quickly and sensitively regulating your baby’s affect states and being dependable and available, especially in the first few months of life, are essential for brain development and for how we physically and emotionally will deal with stress factors in the future. But in order to bring up a securely attached child with a firm sense of self, someone who can relate but also has developed into an autonomous human being, a child has to go through a process of ‘optimal frustration’ (Winnicott, 1971). It is developmentally essential that a child goes through a phase of feeling omnipotent, but it is equally important that the caregiver ‘weans’ the baby off the notion of being omnipotent, by introducing boundaries and by very gently and gradually introducing frustration and delayed gratification. This is also necessary in order to teach a child how to deal with feelings of anxiety, frustration and anger in a healthy and constructive way (Bowlby 1973). Furthermore it is important for the development of a sense of autonomy and agency, and encourages self-initiative (Stern 1985). This explains why the weaning process is highly significant developmentally, and leaving it totally up to the child as to when to stop breastfeeding means losing out on the opportunity to utilise this process. Alice Miller and Heinz Kohut agree that the gradually increasing frustration of the child’s narcissistic needs is vital for the development of a healthy sense of self. It is essential for the consolidation of the self, to develop self-confidence and self-esteem, to become resilient to deal with life’s difficulties in positive ways, for one’s objects to become real, and to be able to conduct ‘reality checks’ and to relate without having to merge. You need to have separated to a degree in order to be able to relate and to be securely attached.

This article is primarily intended to clarify what attachment-based psychotherapy is and is not about. If you have different experiences of attachment parenting than the kind portrayed by the media, please leave a comment below.

Further reading:

Bowlby, J. (1988) A Secure Base: Parent-Child Attachment and Healthy Human Development. London: Routledge

Bowlby, J. (1973) Separation: Anxiety & Anger, Attachment and Loss (vol. 2). London: Hogarth Press

Holmes, J. (1993) John Bowlby and Attachment Theory. London, New York: Routledge

Sears, W. and Sears, M. (2001) The Attachment Parenting Book: A Commonsense Guide to Understanding and Nurturing Your Child, New York: Hachette Book Group

Stern, D.N. (1985) The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic Books, Inc.

Winnicott D. W. (1971) Playing and Reality. London: Tavistock

Winnicott, D. W. (1957) The Child and the Family. London: Tavistock

Winnicott, D. W. (1957) The Child and the Outside World. London: Tavistock

The findings of the The Centre for Economic Performance’s Mental Health Policy Group are shocking but don't come as a surprise to many in the profession - there is a 'massive inequality within the NHS' in the way it treats mental illness compared to physical illness. Facts from the report first, my experience as an NHS Honorary Therapist and and Attachment-Based Psychotherapist in Training later.

According to the report, which was written by distinguished economists, psychologists, doctors and NHS managers, almost half of the health problems of under 65s in the UK are mental illness (mainly depression, anxiety disorders and child disorders). Despite mental illness often being more debilitating than physical illness, the NHS only offers treatment to 25% of mental health issues, compared to the fact that (arguably) most physical illnesses being treated. One of the reasons given is that NHS commissioners have failed to adequately commission the health services that NICE recommend.

The report emphasises that the need for changes in policy is urgent, but that currently the NHS is cutting mental health services rather than expanding them, which would cost the NHS nothing. Mental health problems can make physical symptoms worse and can even cause them in the first place. Frequently, patients with 'medically unexplained symptoms' get referred from one specialist to the next, without any improvement. Treating physical symptoms caused by mental illness currently cost the NHS £10 billion, which according to the Mental Health Policy Group would be better spent on psychological therapies, where the cost is low and the recovery rates are high. They found that about half of those suffering from anxiety disorders and depression respectively recover after an average of only ten hours of CBT, permanently.

This report exposes the extent of which NHS policies focus on short-sighted, often inadequate treatments of symptoms, rather than tackling their real causes. It is not rocket science to figure out that that is not an economical way of going about it, and not a very healthy one either. I know of GPs refusing blood tests to patients complaining of tiredness, but instead wanting to prescribe them anti-depressants, having spent only five minutes with a patient they have never met before. (Interestingly, the use of anti-depressantsand other types of medication are not addressed in this report.)

It is vital that these issues are brought to public awareness emphasising the urgent need for change, especially since such change would be self-funding. It does, however, come from a rather medical perspective, and many psychodynamic psychotherapists have concerns about the bias towards Cognitive Behaviour Therapy (CBT) in new NHS guidelines. Recently, over 6,000 practitioners have signed a petition against NICE guidelines in the IAPT programme. Psychodynamic psychotherapies tend to be open-ended and unstructured, making them much less attractive for the NHS, not because they aren't proven to be highly effective, but simply because their 'success rates' are much more difficult to statistically quantify compared to CBT, and because they tend to have a longer duration. Psychotherapists' criticism of this bias is indeed justified, but it has to be put into perspective: A course of CBT is usually the first treatment offered by the NHS, but in a way it is only a starting point. Yes, it is unlikely that 12 sessions of CBT will cure every mental illness. The facts are that it has varying success rates for different illnesses. But to say that CBT is generally unhelpful is also inaccurate, since it does reduce or alleviate many patients' symptoms, and often permanently. For the 50% who do not recover after a course of CBT, and especially if a patient is persistent enough, the NHS has fantastic things on offer, and I was unaware of this before my time as an NHS Honorary Therapist: GPs, psychiatrists and community health teams further evaluate and can offer patients up to one year of psychoanalytic psychotherapy, various group therapies, as well as 18 months of Mentalisation Based Therapy (MBT). Amazing resources are available within the NHS, but the fact that they are not frequently mentioned is symptomatic of the inequality mentioned by the report.

It is also pointed out that, unbelievably, and despite the IAPT programme, mental health services are still being cut rather than expanded. The personality disorders service I am working at have been subject to these cuts, losing around half of their staff over the last year, and as a result having to reduce the amount of patients they are able to treat. Waiting lists and waiting times are long. The criteria of admission to the service has been changed from moderate to severe personality disorders, which means only individuals who currently self-harm are taken on. As a result many individuals continue to suffer from their personality disorders, as well as those around them. The cost to society (and other NHS services, e.g. A+E) will also be increasing as a direct result of these cuts, since many personality disorders come with drug addiction, suicide attempts, unemployment, self-harm, crime, anti-social behaviour and violence. These changes now lead to a situation where individuals with mild or moderate PDs go through lengthy assessment procedures, only to be told that they can't benefit from that particular service, after which they are transferred back to the general psychotherapy service. Often they fall through the occurring cracks of the current system.

This leads straight to some of the advantages of psychotherapy services outside of the NHS. Psychotherapists in private practice are independent (apart from their regulating bodies' ethical guidelines) and don't have to follow frequently changing government policies. This enables them to offer a more consistent treatment and to fine tune the therapy according to the client's needs rather than being driven by having to meet targets and fulfilling quotas. Attendance, motivation and results tend to be better if the clients / patients actually pay for their sessions. Navigating through the NHS system trying to get help often means being on long waiting lists, going through assessments, being denied certain therapies, being referred back and forth and having to deal with a great deal of uncertainty and additional anxiety along the way. It can be experienced as feeling forgotten, feeling like a burden, and feeling rejected. In a sense only those able to be persistent and proactive enough to 'work the system' are likely to get treatment, leaving it inaccessible to those who need it the most. Trying to get NHS treatment for mental health issues frequently inflames the very vulnerabilities and difficulties that a patient is seeking help for. Ambivalent attachment at its best. This should really be avoided. Private practitioners try to offer a sense of stability and security from the beginning.

Psychodynamic psychotherapy circles tend to be rather critical of the NHS's mental health services, and especially CBT. The problems in the private sector of this profession is that often those most in need of intervention are unable to afford the rates that we need to charge in order to make a living. The training organisations make sure that their trainees offer long-term therapy at minimum wage for unwaged training clients, and registered therapist often still offer low-cost therapy, but, since training costs and running costs are high, and this is our income, the average of £60 or £70 a session will be the bulk of a private practitioner's work. Whilst making a valid point, some of the criticism might be coming from anxieties about professional survival in difficult economic times. Most importantly, the main focus should be to get those suffering from mental illness access to efficient treatment, and that means the NHS having to offer more psychotherapeutic treatments, including longer term psychodynamic ones, not just CBT.

The report 'How Mental Illness Loses Out in the NHS' by The Centre for Economic Performance’s Mental Health Policy Group can be downloaded for free at
http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp

Silke Steidinger 1/9/2012