Bowlby's trilogy

Summary

John Bowlby's ‘Attachment and Loss’ trilogy set the scene for half a century of attachment research and theorising. This article picks out the key themes of his work – the attachment dynamic, the impact of trauma and life events, defensive exclusion, loss and bereavement, and internal working models – and points to their continuing relevance.

John Bowlby (1907–1990) was arguably the most significant British psychiatrist of his generation. Coming from a background of pressurised upper-middle-class neglect, he found his vocation as a medical student while working in a progressive school. There, alongside his intellectual brilliance and drive, he discovered a capacity for communicating with unhappy children, and went on to train in child psychiatry and psychoanalysis. His trilogy Attachment (Bowlby 1969), Separation (Bowlby 1973) and Loss (Bowlby 1980) form the foundation stones for what has come to be known as attachment theory (Holmes 2014). Despite their somewhat patrician and all-encompassing voice, their freshness and originality shine across the years. In what follows I shall summarise their key concepts and point to ways in which attachment ideas continue to inform today's psychiatric theory and practice.

The attachment dynamic

Alongside his basic training in ‘Cambridge’ science, psychoanalysis and Kraepelinian psychiatry, Bowlby acknowledges three main influences. First was his experience of wartime psychiatry, when he helped pioneer group and milieu therapy for treating trauma. Second was the novel discipline of ethology, which brought a Darwinistic approach to naturalistic studies of animals in their environment; Bowlby drew on this in his famous filmed observations of the impact of maternal separation on young children when admitted to hospital. Third was the science of cybernetics, in which an individual psyche, mother–infant dyad or family could be seen as systems in which feedback, positive or negative, determined outcomes.

Out of these intellectual currents emerged the trilogy's central concept: the ‘attachment dynamic’. Bowlby saw this as a psychobiological ‘drive’ comparable to the psychoanalytic emphasis on sex and aggression. Volume 1 describes how, when faced with stress, illness or threat, children inhibit exploration and play, and seek out and engage in reciprocal ‘goal-corrected’ feedback with an ‘older wiser’ figure, ‘secure base’ or safe haven for protection until the danger has passed (Bowlby 1969).

The attachment dynamic, although less obviously, applies equally to adults (Mikulincer 2016). Health professionals ignore the attachment dynamic at their – and the patient's – peril. From the latter's point of view the psychiatrist–patient relationship is fraught with danger: seeing a psychiatrist will inevitably elicit the attachment dynamic, which inhibits the very mutual exploration of symptoms and difficulties that the psychiatrist expects. As their relationship deepens, however, the psychiatrist may assume the role of secure base to whom the patient will turn in times of difficulty. This too needs to be understood and acknowledged. The ‘churn’ of rooms and professionals which current National Health Service (NHS) practice engenders is especially inimical to assuaging the dynamic and impedes productive working relationships.

Attachment styles

Bowlby's co-creator of attachment theory was the Canadian psychologist Mary Ainsworth; it was she who devised the strange situation procedure (SSP) and trained the next generation of attachment researchers. The SSP has now been used in over a 1000 peer-reviewed studies and classifies patterns of attachment in parent–infant dyads on the basis of how they handle a brief separation (Slade 2023). These fall into four categories: secure, and three ‘insecure’ types, anxious, avoidant and disorganised. Long-term studies show that attachment styles in infancy, while far from irreversible, predict later character traits; disorganised attachment in particular is associated with adolescent psychopathology.

Following the SSP, Ainsworth's student Mary Main devised the second most significant attachment theory measure, the Adult Attachment Interview (AAI). The AAI defines adult attachment styles in ways that parallel those of infants in the SSP. The innovative aspect of the AAI was that it used adults’ discourse style, rather than informational content, as a pointer to their attachment disposition. Mental health professionals will be familiar with the fact that people talk about themselves and their life experiences in very different ways. In the AAI classification, ‘secure autonomous’ people speak freely, cogently and with appropriate amounts of detail and affective colouring. ‘Dismissive’ people's accounts of themselves tend in the opposite direction. When asked about their family and upbringing they might respond ‘Oh, you know – just normal’. The ‘enmeshed’ style is prolix, unfocused, lacks temporal markers indicating whether the present or past is being described, and is hard to engage with in a dialogic way. In the ‘disorganised’ pattern, the person's speech, which in other ways may fall into one of the previous modalities – ironically, including ‘secure autonomous’ – contains breaks in logical continuity, suggesting that trauma-derived memories are interrupting the speaker's train of thought.

Life events

In contrast to his psychoanalytic mentors, Bowlby's experience in child guidance clinics and with war orphans convinced him that children's psychopathology resulted not from inbuilt dispositions and conflicts, but in response to adverse life circumstances:

‘ … no one who has worked for long in a family clinic, in which disturbed children and their parents are treated, still holds the traditional view that actual experience is of little consequence’ (Bowlby 1973: p. 241).

Brown & Harris's pioneering studies of depression were influenced by Bowlby's carefully adumbrated case for this in the trilogy, and the now widely accepted research on adverse childhood events confirms his supposition (Holmes & Slade 2017).

Bereavement

Humans are born in a state of extreme dependency and, in our environment of evolutionary adaptation, vulnerability to predation. One of the key evolutionary functions of attachment is to ensure proximity to protective parents, in whom separation from their infants stimulates an equally compelling caregiving attachment dynamic. As described in Volume 2, Bowlby's studies of children separated from their parents when admitted to hospital convinced him that, contrary to popular views at the time, children suffered from grief and sadness with no less intensity than adults (Bowlby 1973). He saw the phenomenology of loss and subsequent bereavement in terms irreversible separation from an attachment figure. Volume 3 of the trilogy describes his student Colin Murray-Parkes's account of the pathways through grief: denial, anger, searching, despair, internal symbolisation of the lost loved one and (partial) acceptance (Bowlby 1980). Working with pathological grief – denial or despair – is a daily task for practising psychiatrists.

Defensive exclusion

Bowlby was troubled by the psychoanalytic notion of defence mechanisms and repression, which he thought did not clearly differentiate between necessary or ‘healthy’ defences and those associated with pathology. He adopted the term defensive exclusion, implying a modular mind able to segregate adaptive attentional and behavioural strategies from those likely to disable or overwhelm. Thus in avoidant attachment, the painful affects of anger and anxiety are excluded so that the child can maintain a degree of non-conflictual safe contact with their caregiver. Striking a balance between modularity and integration, and ways in which psychotherapy can help move people from the former to the latter, are significant research themes in relational neuroscience. Valliant's long-term studies of life courses, favourable and unfavourable, also draws on this distinction (Holmes & Slade 2017).

Internal working models

Alongside his interest in evolutionary ethology Bowlby was influenced by Kenneth Craik's anticipation of the ‘cognitive revolution’ of the 1960s. Far ahead of his time, Craik, like psychiatrist Karl Friston in our era (Holmes 2020), realised that perception is not a pristine reflection of the world, but depends on pre-existing ‘top-down’ models of the world aligning with confirmatory or disconfirmatory ‘bottom-up’ evidence provided by extero- and enteroceptions.

Bowlby's ‘internal working models’ (IWMs) were his formulation of this idea as applied to relationships, seeing them as largely unconscious childhood-derived assumptions about self, others and their relational interplay, in health constantly updated and reworked. Arguing that an individual's inner world may include multiple incompatible IWMs, he retained the psychoanalytic notion of the conflict and saw psychopathology as also arising out of IWMs applied anachronistically to current relationships, including those with therapists and psychiatrists. Bowlby was a synthesiser whose guiding principles were evidence and coherence rather than espousal of any particular psychological ideology. IWMs are thus an important bridging concept between cognitive constructs, such as faulty assumptions and schemata, and the psychoanalytic ideas of phantasy and transference.

Reflexive function and mentalising

With his systemic cybernetic background Bowlby was interested in the parts played by appraisal, regulation and feedback in psychological health and illness. Here, in his step-by-step, logical way he states:

‘much of the work of treating an emotionally disturbed person can be regarded as consisting, first, of detecting the existence of influential models of which the patient may be partially or completely unaware, and, second, of inviting the patient to examine the models disclosed and to consider whether they continue to be valid’ (Bowlby 1973: p. 239).

The process of appraisal of IWMs stimulated the concept of reflexive function and its protective role when faced with environmental disruption or trauma. This in turn has now morphed into the burgeoning research and practice literature on mentalising (Bateman 2016) as a key therapeutic intervention in a range of psychiatric disorders. There is good evidence that acquiring mentalising skills can help break the intergenerational transmission of insecure attachment and promote psychological health despite trauma. Bowlby's ideas about appraisal and feedback are its direct progenitors.

Conclusions

Encapsulating half a century of Bowlby and his collaborator's work, the Attachment and Loss trilogy was a nodal point in the evolution of attachment theory. It paved the way for the huge expansion of Bowlby's ideas in the years that followed and continues to this day. Attachment & Human Development, currently edited by Howard Steele, is a top journal in the field. Cassidy & Shaver's (2018) Handbook of Attachment is now in its third edition and Duschinsky's Cornerstones (Duschinsky 2020) meticulously traces the ramifications of attachment research. Holmes & Slade (2017) outline clinical implications. Curiously, despite his fame, Bowlby himself was rather a remote figure within psychiatry and psychoanalysis. Perhaps the very monumentality of the trilogy was off-putting. But there is hardly a chapter within it from which today's psychiatrists and mental health workers cannot benefit. Travelling with the trilogy is no sentimental journey, but a much-recommended mind-expanding pilgrimage.