The Hunger for Attunement: The Poetry of Mind and Brain

There has been an increasing shift over the years, among psychotherapists as well as the general public, from a primarily psychosocial model of behavior to that of a genetic-biological model. It is very common in my practice today to hear patients explain their problems, or those of their children or loved ones, in terms of bad brain chemistry, whereas a decade ago the most frequent explanations centered on psychological demons such as “complexes” or growing up in a dysfunctional family.

The change is due in part to the thrill of the current neurobiological explanations that are the rage this day in both public and professional journals. The seeming simplicity of such answers (i.e., it’s in the genes) to remarkably complicated questions (e.g., what causes addiction? why is someone depressed?) is quite alluring. To fall for this is, I believe, just human nature. Part of the change is due as well to a justifiable reaction to the blame that was implied, intentionally or otherwise, from early psychoanalytic models of socialization that over-emphasized faulty parenting to the neglect of other factors.

The research in both developmental psychology and neuroscience is admittedly compelling in its explanatory robustness, and is exciting in terms of its implications. Yet despite the exhilarating advances in these fields, human behavior is not, as some
writers would like to claim, simply reducible to biological factors. In fact, we are
discovering some curious things, such as the importance of what might be called
relational style. Just as in literature, in parenting there is an important distinction
between what is said and how it is said, between content and style. In the intense
and nuanced relationship between parent and child it is as much about the mother’s tone of voice, the cadence of the father’s speech, the rhythm of the caregiver’s
embrace, and the melody of the sounds co-created by parent and child, as it is
about the words actually spoken (Ainsworth, 1985, Main, M, Kaplan, N, and
Cassidy, J., 1985).

Such findings are resulting in more subtle discussions of the role of nature versus nurture, to the degree that for most researchers, the century old debate about which is more important has been all but discarded. It is not, however, a simple reinforcement of what we already know, which is that children raised by thoughtful, attuned parents tend to be much better adjusted than those who had neglectful and abusive ones?

Just as we had suspected that depressed people do depressing things, it is nevertheless helpful, for a discipline desperately wanting scientific credentials, to have these notions scientifically verified. In the current research we are getting a lot more than just verification of what we think or believe to be obvious (and I am not knocking research that does this; it is important to work to be done). What is especially provocative is that it shows a complex interplay between nature and nurture, especially around how early attachment experiences significantly influence neurological development.

“Good enough” parents help their children, by way of appropriate mirroring and attunement, to accurately read, both cognitively and emotionally, the world
around them. If all goes well, the child learns a sophisticated language that allows her not only to identify and articulate her inner world but also to make fairly accurate interpretations of the desires and intentions of those around her. If
the environment is sufficiently rich, the brain develops in ways that continue to
facilitate the development of pro-social abilities.

It becomes, as the psychologist Louis Cozolino calls it, a social brain. Parental neglect and other forms of trauma result in the child’s brain needing to accommodate a harsh environment and thus developing differently. The brain, in the face of such relentless psychological pain, shuts down in a sense which makes it more difficult to be in touch with the psychological wounding that is taking place around it. Unfortunately, what also gets lost is access to important data about one’s inner life.

This “good enough” parenting is of a very special sort. It requires that the
caregiver appreciate and acknowledge the developing mind of her child. This is
done by mirroring the child’s nascent desires and intentions, repeatedly, unconsciously—and importantly, imperfectly—hundreds of times a day. The attunement and mirroring need to be accurate enough that there is an overlap between the infant’s core experience and the representation by the caregiver, but it cannot be too perfect. If there is too much overlap, if the caregiver, for example, reflects back as much rage, sadness, or distress as the infant feels, the infant will be understandably overwhelmed, if not traumatized.

Here is an example to illustrate a fairly mundane episode between an infant
and caregiver: a toddler falls into a shallow pool of water and gets nice and wet.
She is not hurt, but understandably starts to cry and seek out her mother. The
mother, right behind, her, picks her up, and says something soothing along the
lines of, “Hey sweety, you are all wet! You must be really cold! I bet you need a
big hug.” She says all this with a concerned face, a soft voice, and soft pats on the
back. And along with these comments and gestures, all of which show that she
recognizes her child’s emotional distress, she also smiles, jokes a bit (very
gently), and might even make an exaggerated frown, indicating in a very subtle,
but very important, way that what she, the mother, is feeling is not identical to
the child’s.

The child learns from this experience, and a thousand some others like it, that her own experience(s) are similar, but not exactly the same as those of her mother. With increased exposure to such well-attuned, but imperfect mirroring experiences, the child learns that she has her own unique set of complicated feeling states, and that others have their own. Within a couple of years she will start putting these feelings into words, describing her own, as well as others’, behaviors in terms of desires and intentions.

What is important here is that the caregiver makes the assumption, which is generally far outside of awareness, that her child is a thinking and feeling being, with her own thoughts, desires and intentions (Fonagy, P, and Target, M, 1997). She treats her as if she has a mind of her own, and from this, her child actually develops the capacity for one (at times much to her consternation, but that is a different matter).

Another way to understand this research is to see how it is making clear that
the ability to make meaning—that highly subjective, hard to pin down notion—
plays a critical role in whether or not children grow up to be healthy social animals. It is a curious and somewhat ironic phenomenon that science is documenting how essential the child’s interpretation of her environment is. The uniquely
personal way each child sees the world, and the way that this uniqueness is mirrored back by sensitive parents, is critical to the development of a psychologically
and neurologically adaptive social brain.

It illustrates what I believe has always been one of the most difficult aspects of studying human behavior, which is that our “beingness” is a unique combination of the biological, social and linguistic. Lacan (1973) was the first to emphasize this, stressing that in addition to being human beings, we are also “parle etre” (speaking beings). It is only through studying how these three factors interact that we get to a more complete understanding of human nature. Studying each in isolation fails to capture the reality that our mind, in many ways, transcends (or if you prefer, modifies) our biological and social self, while the other two likewise influence the others.

One can think of a Borromean knot, in which the three intertwined rings exert pressure on each other, and in which each ring is needed to create the knot. If one is missing, the knot dissolves. Having language skills and the neurological apparatus for thinking does not necessarily mean that one will have the skills to negotiate adequately the complex social world in which we live. Parental neglect and other developmental traumas inhibit the acquisition of reflective function—the capacity to tell the difference between one’s subjective inner experience and outer reality—as well as the development of the skill of knowing the difference between those emotions that take place within the subject versus those which are created interpersonally. As the psychoanalyst Peter Fonagy (Fonagy et al., 2004) succinctly put it, “Having a mind is not a genetic given.” And not to have a mind, in other words not having the ability to being mindful, makes for painful relationships.

For optimal growth, human development thus entails two codependent processes, the development of a healthy brain and the development of a healthy mind,
both of which need a robust and safe environment for optimal ontogenetic expression. The two are interrelated in ways that imply that, for our species, meaning has just as much, if not more importance, than biology. In philosophical terms, the irreducible subjectivity of the inner life of the child, what makes her uniquely human, is made possible only by having others around who also have this feature and who see it in her (in some ways even before it is there). The primary features of mind, which are that we are able to read and interpret the desires, intentions and emotional states of our selves and of others, depend heavily on the emotional timbre of our earliest relationships.

The affective colorations, and the rhythms in which we were soothed and held, stay with us unconsciously in the form of procedural memories, these being those memories which carry the “felt sense” of our early relations, before language. These memories are more intuited than they are thought, and more sensed through lived relationships than they are through symbolic discourse. At this level it is as much about poetry as it is about biology. It is not just what we were told as a child, but how we were told. Not just that we were held, but how were held.

I think we all know this intuitively, but it is nice to have it proven. Confirmation of this fact does not make the therapist’s task any easier. In fact, it just adds further dimensions to the already multifaceted skill set that our work entails. I believe it especially calls into question the cherished, self-proclaimed status of “healer” that is prevalent in our field.

I am skeptical about this appellation for a couple of reasons. First, it implies that there was something first broken in the patient that now needs to be mended. This goes in the face of a considerable amount of research in attachment theory of the last couple of decades that suggests that, instead of most pathologies being the result of inner conflicts and psychic malfunction, they are more often than not the result of lack, as in a deficiency or failure in the development of reflective function. If you can’t read your own inner world accurately, and cannot read those around you accurately, you are very likely to have interpersonal problems.

So instead of healing our patients, more often than not we are providing a unique relationship in which unconscious, unsymbolized relational patterns get played out, but with different results (with understanding and with an attempt at reparation of empathic failures, for example, instead of the indifference or disdain that was experienced as a child). Healing also implies that we, in some fashion or the other, are endowed with quasi-magical gifts that allow us to “cure” our patients.

This is another area that we have much to learn from in the arena of attachment theory: there are specific, definable skills that need to be learned by therapists, just as there are similar skills that need to be learned by parents. This is the science of psychotherapy. The art of psychotherapy, as in the art of parenting, is knowing when, and in what ways, to use these skills. I liken it to the difference between reading a score of music and actually having the skill to make music from it on a real instrument.

Psychotherapy is still a young field, and we are just beginning to learn the basics, from a scientific point of view, of what specific things to do, as well as in what ways to be with the patient. In attachment theory, we are coming to understand the musical score, so to speak. Again, content and style overlap.

In reviewing the developmental research from a variety of different theoretic traditions, Karlen Lyons-Ruth (1999) found that there was a remarkable overlap in findings, especially related to what constitutes healthy communication systems. She summarizes four essential skills that define “coherent communication,” that is, “…characterized by active negation and repairing of miscues, misunderstandings, and conflicts of interest.” This type of communication is open, honest, and mutually regulated and describes not only the best of parental attunement, but the best of therapeutic engagement, as well.

According to Lyons-Ruth, coherent communication consists of:

• • Active structuring of dialogue around eliciting the child’s current and emerging wants, needs, views, likes.
  • Both the importance and the difficulty of knowing
    another’s mind are explicitly acknowledged.
  • Active pursuit of repairs when misunderstanding occurs: Need for mutual con- tribution to regulation and repair is explicit.
  • Active bridging of dialogue to new levels of awareness by the developmentally
    advantaged partner
  • Paradox that the relationship is mutually regulated in the face of developmental inequality.
  • Active engagement and struggle with the child through transformational periods when awareness of self and others is being reorganized, with attendant recalibration of the extent of the child’s initiative and direction of the relationship.
  • Paradox that the relationship initiatives are balanced in the face of inequality of power. (1999)

As Lyons-Ruth and other writers such as Jeremy Holmes (Holmes, 1999) and
David Wallin (1999) have proposed, our work as psychotherapists entails providing much of the same ways of relating, but also entails addressing the damage(s)
caused by the lack of these relational qualities earlier in the patient’s life. Again,
the therapeutic community has known this intuitively since Freud, but it is now
being corroborated by infant research, cognitive science and neuroscience.

How does this relate to the day-to-day of work of therapy? One way to do so
is to understand that the patient is going to, over time, do in therapy—in his or
her relationship with us—what he or she does in other relationships. This will
be done despite whatever is actually said by the patient, meaning that there is
often going to be a disconnect between the patient’s actual words and his or her
behaviors.

Returning to what I referred to above as relational style, the patient’s fundamental relational issues will more often be “felt” by the therapist than understood cognitively. And there is nothing magical about this. The “feltness” is a
result of unconscious narratives being played out in which the therapist is being
inducted to be a primary character. It is something we all do—it is felt by others
by the way that we do it, not in the words that we use.

The reason for the disconnection between words and deeds—relationally
speaking—has to do with there being two relatively distinct types of memory
pathways involved. One of them is declarative or conscious memory of those things that we can name and talk about, and have words for. The other is procedural memory, which is the memory we have for how we do things.

We are generally unaware of this type of memory, as it is manifested in our actual doing of things rather than our talking about them. For instance, it is the memory we
have of how to ride a bike or how to use a sewing machine. It is also the memory
we have for how relationships are done.

Attachment research shows that the basic patterns of our relationship styles—which  mostly have to do with relationship expectations such as whether or not people in our life are trustworthy, dependable, safe and so forth—are learned before language acquisition and are far out of our awareness. Words come later, and as most seasoned therapists know, are often effective in masking the truth about what is actually being felt at a gut level.

A patient, for example, may say he generally trusts people, but we learn that his
behaviors belie this, and that another patient may deny her fear of intimacy, but
likewise push people away in ways that she cannot see herself. The best knowledge we can have of our patients is the knowledge that we glean from actual contact with them in the hour-to-hour, week-by-week sessions for which we provide a setting that is safe, full of inquisitiveness, and boundaried. It is through the actual playing out (and living out) of the patient’s procedural narratives that the real story unfolds.