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The book traverses the well-worn trails of self-destructive patterns and how these patterns may emerge as a result of insecure attachments and other issues related to the various models of attachement. Drew Pinsky of Dr Drew fame has showcased her talents, which seem to include blonde appeal for the cameras to add to her qualifications at the University of California.
Chapter One thus goes over attachment theory, the bilateral way infant and parent bond, and the chapter finishes with end of chapter exercises, and a takeaway message. These last two include being curious as to whether you look your partner in the eyes when making love, and validation attempts by your child for instance.
As has become de rigueur for any such work, a brief intro to the brain appears next (albeit 9 pages only) as attachment and the developing brain are discussed. Several pages on the salience analysis of stress then follow, as well as some instruction on memory. An interesting discussion appears in a box on page 74 describing why 'Ferberizing' a child, namely letting it cry, is actually child abuse. I found this somewhat amusing and culturally loaded. The French for instance have a different view. They will definitely refuse to comfort a child who won't sleep, and will leave them to cry it out. Not only that, but the French also spank their children with no law against it. French kids are fed four times a day, and snacking is out of the question hence low obesity rates compared with US kids. Whilst ADHD rates are at about 5% in the USA, they are at about .5% in France. Which country, by the way, does not use the DSM series for classifying mental illness, rejecting it on the basis it is heavily dependent on a drug-treatment rather than multifactorial model, so they have their own classification system. So the French do not see the "absurdity and cruelty" of this model, and as far as I know, the French are pretty okay in most respects.
This does not mean she is not right, but any position a psychologist takes on any issue really could be argued several different ways. By her reasoning, the predicted nasty attachment issues of an abused child should predict huge issues mentally later in life, but as Scott Lilienfeld and others have frequently pointed out, as the French would hold out as true as well, children often learn surprising resilience in the face of adversity. I have seen parents precisely abuse a child who doesn't nod off in a disciplined way, instead of leaving the child to cry and rescuing themselves. So such seemingly correct and intuitive pronouncements in a self-help book are often contentious.
Her commentary on Stuck Impulses is also quite extraordinary, and she does not explain how 'stuckness' occurs as Dr Peter Levine describes it, nor why there are so few publications in the field. Nor does she really state how trauma, which we know is highly predicted by early childhood experiences, including family violence, relates to ordinary human beings trying to conquer their self-destructive urges. Walking around the world safe and calm is described as a natural state, but looking at the wiring and the need to mitigate threat and maximize reward, her model is seriously lacking in credibility, and simply she refers to two elements of the autonomic nervous system as if they were entirely devoid of the Vagus nerve, GABA, Glutamate, NaG, Vermis, and the entire enteric nervous system for instance, not to mention Neuropeptide Y, and so on. So we are focussed on a very small but salient aspect of the CNS, as if it were a simple balancing act, and some phenomenon whereby emotions get 'stuck' in the body after a fashion.
I do however like the few lines she devotes to the body remembers, the idea that emotions are somatic, experienced as feelings, but she is not in the class of Damasio when it comes to the feeling of what happens. Reference for instance to the integrate model, and how the neurotransmitters are involved with salience and thought and feelings, might have been a better way to go than psych 101 Hans Selye.
Her discussion on page 90 is a little confusing. Ambivalent attachment would predict that a person coming in close would be reassuring; a person walking away would provoke a desired attachment response, with fear. This would be astounding if attachment were so simple a concept, that for instance your rapist leaving your immediate presence would provoke an attempted attachment, if we take this argument to its illogical end; this would be perhaps more easily phrased as your rapist would leave you feeling guilty perhaps that you caused the rape? Attachment is really a two way street, a tricky, non-linear system of bonding (see http://www.mentalhelp.net/poc/view_doc.php?id=2286&type=book&cn=91 for instance). The same non-linear vs. linear causality issues used to occur in the 'double-bind' theory created by Gregory Bateson, in his theories on psychosis. Soon, therapists were convinced that the 'double-bind' somehow caused the psychosis, which of course is a linear operalization of the concept, which is meant to be self-recursive and non-linear in causality terms.
In this regard, the work of Dr Ruth Blizard has a lot more to offer: http://www.ruthblizard.com/articles and more again in her work on dissociation, part of trauma and ongoing issues.
Other references are quite troublesome, including as to why some people get PTSD, and some do not. Another issue is the testing which suggests that your partner's approach to you might make your heart beat faster, if you are avoidant in your attachment. I personally have experienced much of the excitement of my partner's or any other loved one's approach, and it has nothing to do with avoidant attachment, nor am I relieved when they walk away, just because my heart rate slows. A thudding fast heart is also I believe a sign of excitement and the threat of sex. Yay. Not avoidant. So I am unsure of the justifications here in this chapter, and as much as I like the song The Look of Love, I am not sure if the absence of the discussion of the orbicularis and the zygomaticus and their effect on neurocognition is sufficiently covered by reference to Porges.
The idea too that primitive defence mechanisms are negative is also contentious, as recent research is showing that they may very well be highly adaptive and useful, not universally damaging in the Freudian sense. Several sentences do not make sense to me, such as "words calm you down more than behaviors do….because you cannot retain the words. You need to hear them again and again and again" (p114). "Unlike people with a fear of abandonment, whose anxiety gets triggered when they are alone, people with a fear of engulfment have increased anxiety when they are with people they love…..A person with a fear of engulfment might also think the people around him will notice how worthless he is and leave him" (p115). Which I thought was a fear of being alone surely?
Anyhoo. The next chapter sets out to identify patterns of behavior. This chapter includes a questionnaire from pages 129-135 with Yes and No answers to be circled. Some items have no Y N so I guess you don't have to answer them. I am unsure how to score a question such as "Did you have a relationship with your mother?" Y N and how this would be part of any cluster of answers that the questionnaire asks me to clump together. Yes I did have a relationship with my mother. Was it good? She doesn't ask that. That would take a psychologist and me years to answer, as would "Were you ever told you were stupid?" Hello, I did have a sibling, and friends, and girlfriends, and teachers etc, of course I was told at times I was stupid. It had no bearing on my life given my four degrees which included cum laude, and the fact I sailed through school. So I am not sure of the construct validity here at all. So far too, I am 64% through the book and no clearer on how to conquer my self-destructive patterns, which I am not sure I have anyway.
But that starts on page 136. The big message is to realize what negative and harmful beliefs you have developed about yourself, based on your past experiences and relationships. Now Google these core elements in existing theories, and you will get between 31.5 and 96 million identical hits, all purporting to convey the same message, which means this is hardly new or innovative. Changing negative beliefs is not easy, she says, "especially before you are even aware of them" which I think is stating the obvious. The same odd reasoning emerges when she consults with a 60 year old woman who never received a marriage proposal. The intuit here was that because the client had lived alone in an apartment at age 12, she had felt no one loved her or she was not worthy, and this was communicated to the client, with "need I say more?" and related to ambivalent attachment. Now when all you have in theory is a hammer, everything looks like a nail. So it may be here. To her 60 year old client, I would wage a lot of money on the issue more likely being a lack of engagement and social skills, rather than attachment issues. No one asked her to marry them because she lacked the skills to engage, having been neglected in her socialization at an early age. Now personally, if I was 12 years old and in my own apartment, I would have had an entire hoard of kids doing unsupervised sleepovers, but if I lacked any social skills, it might have been quiet. I seldom follow Dr Shirley Impellizzeri's logic. Human issues nearly always have multiple and complex aetiologies, and I think learning where a negative belief comes from is unlikely to yield an epiphany even in psychodynamic terms, as tons of reinforcement, in other words as she describes elsewhere, repeated reinforcement of dysfunctional patterns are necessary to impart weakness rather than resilience, and this is usually multifactorial, hard to pin down to any single event.
What follows then is an extreme exercise in finding the reasons, the 'why' did I do that that is the first thing that comes to mind, or comes to mind when focussing on bodily sensation, much as free association did for psychoanalysts. "More often than not, you will discover it is a reaction to something that happened in the past" (p138). Well, given it cannot be a reaction to something that happened in the future, what else would it have been a reaction to? Sorry, this is not making sense to me. If it is only a reaction to what is happening now, then it is contingent on the now, not the why, and otherwise, given as an adult we would have had the same sensation multiple times in the past, living long enough, then which exact event in the past did this emerge from? Multiple events surely, or the patterns she speaks about. We also find we need to set boundaries, need to treat ourselves with love and compassion, and communication is the key. Seriously? A book in 2012 has only that to offer? 4.5 million Google hits, starting with Oprah just for the setting boundaries bit, 2.7million for treating yourself with love and compassion, and 'communication is key' will give you 750million.
Chapter Five confirms that the Freudian view dominates this book, in that once you are able to uncover your unconscious triggers etc (most would use the term non-conscious given the neurology earlier) you will be free so to speak. This I would hold forth is not only not a new concept, but certainly a discredited one, as little evidence exists that this is true now, or was ever true unless one is embarking on therapy with personality disorders, where a psychoanalytic approach is pretty useful.
Since the vast preponderance of evidence based theories exist around cognitive and behavioral principles, the idea of the uncovered unconscious world being revealed in this epiphany-styled way and being useful is a little tired. The vast contribution of the Integrate Model for instance, which she is more or less following in her discussion about the brain earlier, is of non-conscious negativity bias which has no why, being tied to neuroticism, but reveals itself in multiple aversive thinking habits and selective filtering, easily dealt with by a cognitive behavioural model which largely ignores the antecedents in history, and deals with the what is, rather than an totally unverifiable why.
The foreword by Dr Gary Small says that Dr Shirley (no family name used, as if she were Dr Drew) "helps us realize that blaming our parents is not the road to change". In reality, she does teach us that identifying what our parents did, influenced and shaped our development. Now Elizabeth Gould and Vygotsky and countless others have taught since that environment ties the cortical knots of the brain, and our parents, bless them, were actually only part of that environment. By the age of 21, most American kids have amassed 10 000 hours sitting in primary and middle school, and exactly that amount in front of a computer game, 10 000 more hours. About 2.6 years. 61,230 hours were spent sleeping. Our parents, assuming most influence up to school going years, and a few a day, got in exactly the same hours as our computer games and school combined. So perhaps about 50% of our lives until 21. At certain times, peer influences of course outweigh parenting.
In reality it doesn't matter where or how or why you became what you are. What you do, and what you believe will work for you, will help you change as Bandura pointed out. The message here is what works is not new, and what is new…. Well I didn't find anything I could identify as new. And I am not sure any of this works. Her therapies may certainly work, but that is common to any warm relationship between client and therapist.
I have seen no evidence that her self-help book will do anything much, and not nearly as much as she could do one on one. Still, for $16-95 and then $6-95 for shipping and handling, it is just about the same price as an e-publication, ordered by calling 1-800-895-4585 or by visiting www.sunriseriverpress.com so you don't have much to lose. It makes for an easy read, but she never answers the simple question, why is change so hard? It is precisely because we are programmed to be risk averse that change is seen as threatening, and as motivational interviewing and self-determination theory and practice have shown, change is best accomplished in a warm relationship in which you encounter your own resolve, rather than someone weaving a spell of inspiring language or searching for the elusive unconscious 'why?' As one of my favourite clients said, the 'aha' moment was more of an 'oh', and then he moved on.
To be more constructive, Dr Shirley should have stuck to the guns of the more modern era, to the elegant therapies now available, avoiding the traps of a personality based on the unconscious. The non-conscious bias has indeed been proven, neglected by CBT and Positive Psychology for good reasons, and rather than take unconscious pathology as a model, the vast majority of modern-trained change specialists prefer a positive and tactical approach to answer the human dilemma of change management. Ambivalence is a huge issue, when emotions and thinking collide, rather than a complex attachment categorization issue. The point about attachment, as I mentioned before, is that the brain and personality work in self-organizing, recursive, feedback loops, and in terms of attachment disorders, Bowlby (and Ainsworth and others) soon began to show that this was a two-way street, and the quality and the quantity of the interaction bilaterally would define the extent to which the child adapted to separation, a necessary entity to allow both the freedom to interact with the world out there, and the need to feel secure while doing so. The failure of attachment has nothing to do with a client being alone in an apartment at twelve years old, or finding the why behind a trigger necessarily.
The categories Dr Shirley uses are also not universal. Brisch, referenced above, went on to flesh out his typology, with classifications such as 'undifferentiated attachment behavior', 'exaggerated attachment behavior', 'inhibited attachment behavior', 'aggressive attachment behavior', 'attachment behavior with role reversal', and finally psychosomatic symptoms. This second last lot is a bit hard to distinguish from normal firm attachment, but is less reciprocal, and so is linear, not second order cybernetic and self-regulating, and hence it is regarded as pathological from a general systems point of view as Dr Shirley does. As with the Oedipal resolution, and other formulations in the psychodynamic view of things, this is highly variable across cultures.
General systems-based theories of mental illness were often criticized for the perceived neglect of the unconscious in outlining their putative theories of the origins of mental illness as I mentioned above. As with the early criticisms of Bowlby by the Kleinians, many of the near-sacred underpinnings of psychodynamic thought were long abandoned in the new approaches to such phenomena as attachment, as described above by Brisch.
With the focus on the need for evidence based practice in psychology and medicine, definitions of psychopathology based on theories of the unconscious which Dr Shirley confounds with the neurological non-conscious bias realm, fall foul of one of the salient demands of empirical science: the concept of the 'unconscious' as she uses it here remains an untestable hypothesis, one which is not subject to empirical investigation and therefore fails the criterion of falsifiability.
Brisch and Dr Shirley are clearly drawing on effectiveness to tell us if the therapy works, i.e. there is strong external validity but weak internal validity in such a model, when compared to laboratory experiments which attempt to investigate the efficacy of such an approach. Efficacy research is the most scientifically rigorous, in that it relies on randomised clinical trials with a 'double-blind approach', not selected case studies, as Brisch and Dr Shirley do and have done here. In offering us proof of the value of his or her methodology in attachment disorders, and I doubt all of the target audience who find change hard have an attachment disorder, there are more than just the 'unique' aspects of their therapies acting on the systems in which they are working. The efficacy approach thus is said to possess strong internal validity, as opposed to the external validity provided by Dr Shirley's approach approach, which generalizes better to therapy as it is normally practiced rather than to her book.
So for the average lay reader, things may seem agreeable and insightful, but from a more learned perspective and from a more global view of brain and mind as she has brought them together, the approach is not one I could endorse, and I do not believe in reading this book that one will conquer any self-destructive patterns. Those that need such treatment will need her personally, and those that do not, do not.
© 2013 Roy Sugarman
Roy Sugarman, PhD, Senior Clinical Lecturer, Medical School, University of New South Wales, Australia