Dr. Sonkin's Blog

An Interview by David DiSalvo with Dr. Daniel Sonkin

Posted on January 12, 2009 on David’s, NeuroNarrative Blog

Headline stealing advances in neuroscience are increasingly affecting the practice of psychotherapy. Major theories in the therapist’s toolkit are being altered and amplified by research shedding light on how the brain actually works. Attachment theory is among those theories undergoing such change, and Daniel Jay Sonkin, Ph.D. has been among the vanguard of psychotherapists integrating new knowledge with old wisdom.

For the past ten years Dr. Sonkin has been integrating attachment theory and neurobiology in his clinical work.  As one of the early investigators and specialists in the field of family violence, he developed a widely used protocol for treating male batterers. His book, Learning to Live Without Violence: A Handbook for Men is utilized by treatment programs around the world. He is also the author of numerous articles and books on domestic violence and child abuse including, Wounded Boys/Heroic Men: A Man’s Guide to Recovering from Childhood Abuse and Domestic Violence: The Court-Mandated Perpetrator Assessment and Treatment Handbook.  His new book, which incorporates new findings in neurobiology and attachment theory, entitled I Promise, I’ll Never Do It Again, is due out in 2010. Dr. Sonkin recently talked with Neuronarrative about attachment theory, neurobiology and how psychotherapy is changing.

Much of your work involves Attachment Theory. What is this theory, and why has it been a critical part of your practice?

In his landmark trilogy, Attachment and Loss, the British psychiatrist John Bowlby posited a theory of development that contradicted the prevailing psychoanalytic theories of the time and proved to be a revolutionary way of understanding the nature of the attachment bonds between infants and their caregivers.  In his observations of infants separated from their mothers and fathers during hospitalizations, he saw the dire effects of separation distress on the emotional state of the child.  Bowlby’s departure from the traditional psychoanalytic theory at the time was considered heretical, and was ostracized by his peers for many years to come.  It wasn’t until after his death in 1990 that the British analytic community issued a formal apology to his family.

According to the theory, attachment is governed by a number of important principles.  First, alarm of any kind, stemming from an internal (such as physical pain) or an external source (such as a loss of contact with a caregiver), will activate what Bowlby called “the attachment behavioral system.”  Bowlby believed that the “attachment behavioral system” was one of four behavioral systems that are innate and evolutionarily function to assure survival of the species.   The distress produced by the stimulus directs and motivates infant to seek out soothing physical contact with the attachment figure.

Once activated, only physical attachment with the attachment figure will terminate the attachment behavioral system.  The infant is like, as attachment researcher Jude Cassidy describes, a heat-seeking missile, looking for an attachment figure (typically the parent) that is sufficiently near, available, and responsive.  When this attempt for protection is met with success, the attachment system de-activates, the anxiety is reduced, the infant is soothed, and play and exploration can resume.  When these needs are not met, the infant experiences extreme arousal and terror.  When the system has been activated for a long time without soothing and termination, the system can then become suppressed.

Bowlby reported observations he made of 15 -30 month old children separated for the first time from their mothers. He witnessed a three phase behavioral display: protest, despair, and detachment.  He concluded from these observations that the primary function of protest was to generate displays that would lead to the return of the absent caregiver.  Subsequent empirical studies by Mary Ainsworth and her colleagues showed that different attachment strategies existed for infants.  These attachment categories were labeled: secure, anxious-avoidant (referred to as dismissing attachment in adults), and anxious-ambivalent (referred to as preoccupied attachment in adults).  A fourth category emerged in their research that was eventually called disorganized (referred to as disorganized or unresolved attachment in adults). Based on an experience she had in studying parenting in Africa, Ainsworth developed a brilliant method of assessing attachment in the laboratory.

The Strange Situation has become a widely utilized protocol for the assessment of infant/parent attachment.  It consists of a specific series of interactions, separations and reunions of the caretaker with their infant.  The procedure is recorded and analyzed by the researchers.  Specific patterns of behavior are observed with each attachment category.  Secure children are typically distressed at the absence of their caregiver but are quickly soothed upon reunion.  The anxious-ambivalent and disorganized types experience extreme anxiety during separation and seek proximity to their attachment figure upon reunion, but experience varying degrees of anxiety as they approach. The disorganized children are particularly ambivalent upon reunion with their attachment figure, both simultaneously approaching and avoiding contact.  Many of these infants display a collapse of attachment strategies resulting in what some authors have described as dissociated behaviors.  Bowlby described these children as “arching away angrily while simultaneously seeking proximity” when re-introduced to their mothers.

Interestingly, although the anxious-avoidant children seem content in the absence of their attachment figure and not particularly interested in seeking proximity and soothing upon reunion, when physiological measures are taken, these children are quite anxious during separation, but somehow learned to suppress their emotions.

Another development in this field, the Adult Attachment Interview, has allowed researchers to examine the relationship between the parent’s attachment style or strategies and the attachment strategies of their children.  It will come as no surprise that these two correlate very highly. It has been found that the attachment status of a prospective parent will predict the attachment status of their child to that parent with as high as 80 percent probability.

Longitudinal studies of attachment have demonstrated a high continuity between infant attachment and adult attachment patterns.  However, these longitudinal studies have also suggested that changes in attachment status can occur in either direction (secure to insecure, insecure to secure).  The term “earned secure” has been used to describe individuals who moved from an insecure status to a secure status.  However, for the majority of individuals, the manner in which they learned to regulate attachment distress early on in life will continue unless their circumstances change or other experiences intervene.  For many people, the coping mechanisms may become more sophisticated, but the net result (over-activating or under-activating in the case of insecure attachment, and modulation with secure attachment) will essentially continue.

How has attachment theory affected psychotherapy overall?

What I find exciting about the attachment literature is that it gives therapists a new paradigm for understanding affect regulation strategies, interpersonal relationship dynamics and the therapeutic alliance – all of which are important areas of focus in many psychotherapeutic theories and modalities.  It is not as important to formally assess the attachment style of a client (though I personally find it helpful) as it is to know that there are different strategies for regulating attachment distress (hyperactivating, deactivating, dissociation or collapse), and that a particular client may utilize one or more of these strategies in regulating emotions associated with close relationships.  It is also important to realize that over time the therapist will also become an attachment figure. And as the client begins to become attached to the therapist, the therapist can begin to observe and experience first-hand these strategies.

In a paper you wrote (Psychotherapy with Attachment and the Brain in Mind), you mention that neurobiological findings have been uncovered that integrate well with Attachment Theory. What are these findings, and how do they fit?

Well, first of all, it is important to understand that the brain is a very complex organ, and although the scanning techniques have allowed us to literally peak into the brain as it’s reacting, there is a lot more we don’t know that do know.  But let me give you a few findings that I find relevant to attachment theory.  First of all, Bowlby referred to that attachment behavioral system as if it were a physical part of the brain.  Without the benefit of brain scans, Bowlby hypothesized that this was something hard-wired into the human brain.  It turns out, that this was true.  What we have discovered is that the area, right behind the eyes, the orbital prefrontal cortex, is quite specialized in functions having to do with attachment. It turns out our brains are very social, and that the prefrontal cortex seems to be quite important in functions having to do with interpersonal relating.  For example, that part of the brain is involved with emotion regulation, empathy, and facial recognition, just to name a few.  We also know that the prefrontal cortex is not fully developed at birth, and that the fully functioning prefrontal cortex of the parent helps to develop that section of the brain in the infant.  That’s why it makes sense that the attachment styles of parents greatly influence the attachment styles of infants.

And I imagine that the emotional component plays a big part in this.

Yes, one of the areas of the neurosciences that I find most exciting is how our understanding of emotions has evolved. What therapist doesn’t work with emotion?  We all do, whether it is explicit in our orientation or not.  Our clients are emotional beings and as such, they are constantly (as we are) experiencing varying types and intensities of emotion.  One of most enlightening findings in the affective neurosciences is that throughout most of our day we are experiencing emotion.  We may not be having the concurrent feelings (i.e., awareness or mental representation of the emotion), but we are having the emotion just the same.  In fact, we are probably not aware of most of the emotions we are experiencing – and this is a good thing. Although emotions can provide us with important information about an event and help us make decisions in daily life, if not adequately regulated, they can also be distracting from other important tasks at any moment in time.  Similarly, if their importance is underestimated, we are missing important information that allows good decision-making and social problem solving.

For psychodynamically oriented therapists in particular, knowing what we are feeling is critically important to knowing what our clients are experiencing at any moment in time.  Fine attunement to the ebbs and flows of emotion in our own physical being can teach us something about the inner world of our clients.  The more analytically trained therapists will recognize that I am speaking about projective identification.  It turns out that this analytic concept has a neurobiological correlate – the mirror neuron system.  The mirror-neuron system allows our mind to read the intention of others through non-verbal cues.  During the course of a session, we are constantly picking up the non-verbal emotional cues of our clients. Our mirror neuron system, located in the prefrontal cortex of our brain (the attachment center), simulates that state in ourselves.  It has been suggested that this system is the neurological basis of empathy.

You mention that Antonio Damasio’s work has been especially important in understanding the emotion/feeling dynamic.

The work of Antonio Damasio has been very applicable to the practice of psychotherapy. He suggests that the terms emotions and feelings refer to two very different processes.  Emotion can be thought of as the body’s response to an emotionally competent stimulus.  These stimuli are frequently handed down by evolution, but can also be learned.  An emotionally competent stimulus will cause a change in the physical state of the organism – therefore, emotion begins in the body (turns out the body-oriented therapists were quite right about this notion).  Emotional reactions are solutions to these events and may occur completely out of our awareness.  How many times have you come home upset after a particularly difficult day or session and not having the slightest that you were upset until someone asked, “What are you upset about?”  The emotion occurred and a solution was employed without any awareness.  It not until the prefrontal cortex of the brain registers the change in the body and represents it either verbally or non-verbally, that a feeling occurs.  Feelings are mental representations of emotional reactions in the organism.  So, in psychotherapy, a great deal of our work is helping clients not only recognize that something is happening to them emotionally, but also developing the feeling language to express it and the reflective ability to understand it.

Another interesting finding is how emotion is linked with thought.  The notion that thoughts and emotions are separate phenomenon is probably inaccurate.  Damasio has suggested that it is unlikely that one can have a thought without a corresponding emotion.  In fact, we use emotions to make decisions all the time.  We may not be aware of it, but like most emotions, they are operating below the surface to help guide us in our choices.  So, when I am engaged in a stimulating conversation with my client, there is a good chance that there is an emotional subtext that is present.  It may not be always important to make that explicit, but if your client has developed their intellect to compensate for a weakness in their emotional competence, then it is critical that therapists help the client balance out their process with emotional awareness.

In terms of raising children, you also mention “behavioral skill sets that are neurologically based” as being beneficial. What are these skill sets, and how might a parent (or would-be parent) go about developing them?

A big effort in the attachment field today is helping parents being more attuned caregivers so that their infants get the best start in life possible.  Bowlby and Ainsworth, and of course contemporary attachment researchers, focus on the issue of good attunement with the infant. Daniel Stern, author of the Interpersonal World of the Infant, refers to the “attunement” of the caregiver: where the parent is sensitive to the verbal and non-verbal cues of the child, and is able to put himself/herself into the mind of the child.  Secure attachment in the parent is central to this capacity.  When a parent has good emotion regulation skills (sensitivity to his or her own emotions, and those of others) they are more likely to put those skills to use with their infant.  This doesn’t mean that secure parents are 100% attuned.  Just the opposite, the most secure parents are only about 30% attuned.  However, they also know how to repair misattunements.  Personally, I found this information relieving, because no one would expect me to be perfect, I just had to be good at recognizing when I missed the mark, and repair by trying something different until I got it right.  Children can very forgiving by nature, as long as they sense the parent is really trying to get it right.

A big part of parenting an infant is about soothing distress as well as amplifying positive experiences.  The better the parent is at doing that for him or herself, the better they can do that with their infant.   When that happens the child feels what Bowlby called a secure base with their caregiver.  The more this feeling of a secure base occurs, the more likely it will become encoded in the brain as internal working mental models or schemata of attachment, which serve to help the child feel an internal sense of “a secure base” in the world. These positive mental models of self and others are carried into other relationships as the child matures.

Studies on security rates suggest that about 60-65% of the population have secure attachment.  That means that for the most part, they will be sensitively attuned to their infants pretty automatically.  Secure parents can’t always tell you what they do with their infants, but certainly do a good enough job at responding to them and generating secure attachment in their children.  That means about 35-40% of the population has insecure attachment.  The common form of insecure attachment is the avoidant type, followed by the preoccupied type, and the least common is the disorganized type.  This means, these parents have varying degrees of problems regulating affect in an adaptive manner and therefore their infants are likely to develop ways of regulating affect that could be problematic later in life.

So, for parents who tend to have the avoidant type of attachment, the goal is to help them learn more about their own emotions, so that they can recognize the ebb and flow of emotions in their children and respond when their infant is distress, rather than withdraw.  Parents with the preoccupied or anxious attachment, tend to get overly stimulated when their infants are distressed.  The goal for these parents is to learn to turn down their anxiety, or self-soothe, so they can be more aware of their infant’s anxiety and find constructive ways to sooth them. Parents with disorganized attachment often have the most difficulty with their infants in times of distress.  Many of these parents were traumatized as children, or have experienced traumatic losses in their past.

It is important for them to resolve these experiences, so that current events (such as a distressed infant) don’t trigger painful emotional memories from the past.  An interesting study by Mary Main and Erik Hesse at the University of California at Berkeley found that not all of the parents with disorganized attachment experienced loss or abuse.  Some of these individuals had a parent who themselves was abused or experienced traumatic loss in their past and when their infants were distressed, the parent acted afraid of them.  So both a frightening (abusive) and frightened parent can cause disorganized attachment in an infant.

So what can a parent do to improve their parenting abilities?

A combination of education (parenting classes) and therapy (particularly to resolve past traumas, but also to learn better affect regulation strategies) are the best options.  Of course, it does take a village to raise a child.  So getting support from others is also critical.  When a parent feels like they are going to lose it, having another substitute or alternative caregiver nearby is very important.  In my new book, I Promise I’ll Never Do It Again, I am writing about how to develop these adaptive emotion regulation strategies so that people can have more positive parenting experiences, but also more successful interpersonal relationships.  You see – adaptive emotion regulation skills are critical to successful relationships of all kinds.

When you discuss the neurobiology of memory, you make a distinction between explicit and implicit memory.  What is the difference, and why is this distinction important in psychotherapy?

The neurosciences have also helped us better understand the process of memory.  It turns out there are two types of memory – explicit and implicit memory. Explicit memory is a type of memory with which we are most familiar.  It involves the recalling events, data or facts.  It can also include autobiographical descriptions that involve recalling earlier events.  When you are using explicit memory, you know you are remembering something, not that it is happening right now.  You recognize that it’s something from your past.

Implicit memory is a form of memory that may have any one or a number of components including: cognitions, emotions, behaviors, perceptions, mental models, bodily sensations, or skill sets.  Two important differences between explicit and implicit memory are that with implicit memory: 1) you don’t need focused attention for it to occur, and 2) when it’s recalled there isn’t a sense of remembering.  During the first two years of life, while the brain is still developing, most learning is occurring through implicit memory processes. Many attachment-related memories are implicit. When we are experiencing implicit attachment memories, we are not aware that we are experiencing a form of memory – there is just a sense of knowing or simply responding. These implicit memories are often activated by current events that fit a particular emotionally loaded theme.  Take for example my client, John, whose theme was rejection.  He felt very rejected by his alcoholic mother.  Today he is married and his partner wants to go out with friends.  He immediately becomes sullen and withdrawn, which his wife notices.  She asks him, “What’s wrong.”  He says, “Nothing.”  They go back and forth, one thing leads to another, and before you know it, they have a blowout and she leaves angry and hurt.

When we talked about this in therapy, he couldn’t really explain why he got so upset.  When we talked about the feelings he had when his mother would go out drinking, he realized that that there may be a connection between those experiences and his reaction to his wife.  In the attachment field, we could call this past into present.  In other words, a current event triggered something from his past.  And yet he didn’t stand there thinking, “Oh, this reminds me of my childhood experiences with my mother.”  Instead, he just responded in the way that is familiar to him – angry, withdrawn and sullen.  One of the goals of psychotherapy is to make implicit processes explicit, so that the client can then have a choice in responding.  So insight is important, but not sufficient.  John needs to learn about his triggers to implicit memory, and learn new ways of talking about those emotions, rather than acting on them automatically.

From your professional viewpoint, how much has neurobiological research already changed psychotherapy, and what sorts of changes might we see in the future? 

I think we are just beginning to see therapists incorporate these findings into their work.  Unfortunately, there are lots of therapists who have been trained prior to the 1990’s that are just beginning to incorporate this information into their clinical work.  There are many books written on how these neurobiological findings and attachment literature can be incorporated into psychotherapy by great authors, such as Daniel Siegal, Alan Schore, Peter Fonagy, Mark Solms, just to name some of my favorites.  In fact, these findings have contributed to a renaissance for the psychoanalysis field.  There is a new journal called NeuroPsychoanalysis.  The more this information gets out there to the clinical community, the more we will see these findings integrated into clinical practice.

As scanning procedures become less costly, I imagine there might be a time when a brain scan might be able to pinpoint particular areas that need developing, or demonstrate changes in therapy or help determine the best type of medication to prescribe.  Of course, I don’t think the technology and medicine will ever replace good old fashion talk therapy, because you can’t have a relationship with a machine or a drug.  Many people’s problems grew out of problematic relationships in the beginning, and I think in the end, it will be relationships that are a critical factor in healing.  But as we learn more and more about the brain, I believe we have an opportunity to fine-tune our approaches to psychotherapy so that a relatively inefficient method can be more efficient, and ultimately more effective.

For more information about Dr. Sonkin, visit his web site, or his blog.�