Can Secure Base Priming Enhance the Effects of Psychotherapy?
Daniel J. Sonkin, Ph.D.
John Bowlby's attachment theory (1969, 1973, 1980) revolutionized developmental and social psychology (Cassidy and Shaver, 2008), and infant mental health research (Beatrice and Lachmann, 2013). More recently both researchers and clinicians have begun to explore its clinical application as well (Obegi and Berant, 2010). Attachment theory has become a widely accepted concept, whose clinical appeal has grown over the past decade. What is not known as broadly, is that social and personality psychologists have also been interested in attachment theory, primarily in its application to adult relationships (Mikulincer and Shaver, 2010) and group dynamics (Simpson and Rholes, 1998). Two particular social psychologists, Mario Mikulincer and Philip Shaver (2010) through their collaboration, have greatly expanded our understanding of attachment in adult relationships, and in particular, the underlying cognitive and emotional processes that lead to particular attachment behaviors (Mikulincer, Shaver, Sapir-Lavid & Avihou-Kanza, 2009). What is most fascinating is their research on secure base priming which they have been conducting for the past 13 years (Mikulincer and Shaver, 2001). The implications of their findings, as well as the methodology they employed, are very applicable to our work as psychotherapists.
This article will focus on the details of the studies on secure base priming. I will propose a model for utilizing secure base priming in a similar manner as contemporary brain-training programs. I will also discuss how secure base priming can enhance the therapeutic process of earned-security that occurs within the context the therapeutic relationship as well as through security-boosting clinical interventions. Although secure base priming is based in attachment theory, the clinician doesn’t need to be “attachment oriented” because these effects may enhance the positive effects resulting from any therapeutic model.
Attachment Theory: Important Concepts
Attachment theory has been extensively reviewed elsewhere (Cassidy and Shaver, 2008, Bowlby, 2005, Bowlby and Ainsworth, 2013), but there a number of important concepts that will put this article into context for both for the person new to attachment theory as well as the reader already familiar with the theory.
- The question is not whether or not a particular child is attached to a specific caregiver, but it’s the quality of their attachment. The term attachment is utilized in discourse in categorical terms – one is attached or not attached. Frequently people refer to a child as “not being attached” to its parent or “very attached” to its parent. Developmental psychologists believe that all infants attach to their caregivers (Main and Weston, 1981) - it is the quality of that attachment that differentiates children and caregiver dyads. For example, a child that doesn’t seek proximity when distressed can still feel attached to their caregiver. One may ask if the child were distressed, why wouldn’t they seek closeness and/or protection when frightened or distressed? One reason is that the child has learned, through their experience with that particular caregiver, that seeking proximity doesn’t not relieve distress or help solve their problems. So they have learned to down-regulate the natural instinct to seek protection because a particular attachment figure has been reliably unresponsive to the child’s needs. However, if another more reliable attachment figure is available, they are more likely to seek comfort from that person. The same can be said about children who are clingy or what some people would describe as “very attached.” Clingy, or resistant/ambivalent attachment, behavior can develop through interactions with an unreliable caregiver and the clingy behavior can be a way of optimizing a helpful response by the caregiver, not because the child is more attached. A similar statement can be made about many adult relationships. Not seeking proximity when distressed or needing help doesn’t mean a person is unattached or doesn’t love their partner it can simply mean they have learned to down-regulate the need for closeness. Likewise, jealous or possessive behavior doesn’t mean a person is overly attached. They have learned to up-regulate to manage anxious feelings of abandonment.
- Attachment theory is an interpersonal theory. Infants, children and adults have their attachment representations created, maintained and modified through interactions with others. For this reason, attachment theory is the perfect model for MFTs who are specialists in relationships. Attachment theory is also a natural fit for clinicians working from a systems model (Meyer, Wood & Stanley, 2013). The interactions observed between parent and child, and between parents/couples in part evolve over the history of the particular dyad, but also based on their childhood experiences caregivers. Those experiences were encoded in both implicit and explicit memory (ibid) and therefore the resultant attachment behaviors are automatic, and can be altogether not conscious. Psychotherapy is, in part, helping people become more conscious of their unhealthy behavior patterns so that change is possible.
- There are different types of insecure attachment. The terms for the different types of insecure attachment differ depending on whether or not you are referring to infants/children or adults. Avoidant children are referred to dismissing adults. Resistant or ambivalent children are referred to as preoccupied adults. And disorganized children are often referred to as disorganized, fearful or unresolved adults. These classifications are often though of as categorical or mutually exclusive. Individuals with insecure attachment patterns may also be described as either up-regulating (resistant/ambivalent or preoccupied) or down-regulating (avoidant or dismissing). Disorganized, fearful or unresolved attachment involves a pattern of both up-regulating and down-regulating. This particularly form of insecure attachment has been correlated to trauma and/or loss (Soloman and Siegel, 2003).
- The categorical aspects of attachment classification. Attachment categories may be thought of in categorical and dimensional terms. They are categorical in that researchers and clinicians think of individuals having secure or insecure attachment. But even these categories can sometimes be misleading. For example, early studies suggested that a child or adolescent might have a secure attachment with one parent, but an insecure attachment with the other parent (Ainsworth, Blehar, Waters & Wall, S, 1978). As the child develops it starts to develop “generalized” working models of self and others. And these generalized models will manifest in relationship to other attachment figures (La Guardia, Ryan, Couchman & Deci, 2000), particularly in adolescence and adulthood.
- The dimensional aspects of attachment classification. How one measures attachment will in part determine whether or not you are viewing security-insecurity from a dimensional or categorical perspective. The Experiences in Close Relationships Questionnaire (ECR) (Crowell, Fraley, & Shaver, 2008), as well as other attachment assessments, view attachment security in degrees rather than either-or categories. For example, the Experiences in Close Relationships Questionnaire (http://www.web-research-design.net/cgi-bin/crq/crq.pl) deconstructs attachment on two dimensions – anxiety and avoidance. The degree of each will determine whether or not someone falls within the secure range or insecure range, and if the later, what type of insecure attachment (dismissing, preoccupied or fearful). Attachment style is plotted on a two dimensional grid with anxiety and avoidance on each axis, therefore someone can either be mildly secure, or extremely secure; mildly insecure or extremely insecure. A dimensional model of assessment helps better describe individual differences within categories and degrees of severity and/or health.
- Attachment categories are both continuous and discontinuous over time. Longitudinal studies (Sroufe, 2005) have demonstrated that although attachment patterns are persistent, they may also change over time. This, of course, is good news for individuals who have had the misfortune of being born to parents who didn’t have the requisite skills to provide a secure base environment for their children. This is also good news for therapists who are in the business of enhancing attachment security with individuals, couples and families. The Minnesota Longitudinal Study of Risk and Adaption (http://www.cehd.umn.edu/ICD/research/Parent-Child/default.html) has followed individuals over thirty years starting in infancy (~ 12 months). The studies confirm that there is about an 80% continuity rate depending on the population studied (Weinfield, Whaley & Egeland, 2004). Researchers have explored what contributes to changes or discontinuity in attachment status or style (Roisman, Padrón, Sroufe & Egeland, 2002). The most commonly cited factor is a secure base relationship. Most discontinuity consists of people with insecure attachment becoming more secure over time. There are instances of individuals with secure attachment who fell upon such unfortunate circumstances that they developed an insecure attachment state of mind; but many of these individuals were eventually able to regain their secure states of mind, because of secure base relationships.
Attachment and the Brain
Advances in neuroscience and imaging technology have greatly expanded our understanding how attachment categories are related to brain structure and function. In his early writings, Bowlby often referred to the “attachment functions in the brain,” suggesting that there was actual structures or a center for attachment (Bowlby, 2005). Since those early writings, other researchers and clinicians have taken up the cause of hypothesizing the connection between attachment and neural structure and function (Schore, 2012, Siegel, 2012; Fonagy, 2010). We are just beginning to understand these relationships, but there are few important findings that are worth discussing, since they directly relate to the thesis of this article.
Because certain parts of the brain are not fully developed at birth, attachment relationships play an important role in brain development. The area that has been most described in the clinical literature is the development of executive functions in the prefrontal cortex (Siegel, 2012). This part of the brain is involved in a number of very important functions that affect interpersonal behavior, such as affect regulation, social cognition, self-other differentiation, auto-noetic consciousness, inhibition control, and reflective function.
Attachment mental representations of self and others, as well the aforementioned regulatory functions of the brain, are programmed within infants and children as a result of repeated interactions with caregivers throughout childhood. These mental representations and regulatory functions are typically maintained and strengthen over the long course of the child’s development. However, as mentioned earlier, these representations and regulatory functions may also change as a result of interactions with other attachment figures throughout life (including therapists). From a neuroscience perspective, change occurs as a result of the brain's natural neuroplasticity functions. Neuroplasticity is the brain’s ability to change and evolve over time in response to environmental demands and experiences. The first three years of life, because the prefrontal cortex is still developing, is a particularly important developmental period because environment influences (interaction with caregivers) are particularly critical to priming the brain.
Memory also plays a very important role in understanding attachment. Because explicit memory brain structures (such as the hippocampus) are not fully developed until several years after birth (Schore, 2012), all attachment experiences during the first two to three years are stored as implicit procedural memory. Implicit memory is a form of memory where previous experiences help in solving problems or completing a task in the present without our conscious awareness. Priming is a form of implicit memory that is actively occurring in those early years. Attachment patterns are learned through thousands of interactions with caregivers early in life while the brain is still in a critical phase of development. When one is recalling through implicit memory, the individual doesn't have a sense of remembering, they just have a sense of being or doing. This why attachment behaviors, whether secure or insecure, are often automatic and therefore the person is often unaware of what they are doing until it is brought to their attention which often occurs in psychotherapy. A self-reflective or mindful practice that involves identifying problematic behaviors, their origins, as well as behavioral alternatives, is one way to approach the change process.
With these basic principles in mind, let's turn our attention to the focus of this paper - secure base priming and how it can enhance the effects of psychotherapy.
Secure Base Priming
In their groundbreaking study Mikulincer and Shaver (2001), created a research methodology that asks the following question - can we alter adult insecure cognitive, emotional and behavioral responses to reflect more secure patterns in a particular experimental condition? In other words, can individuals with insecure attachment be primed to act more like people with secure attachment? The answer turned out to be yes. This change was accomplished through a process called, Secure Base Priming. Their research methodology has been repeated many times over the past 10 years (Mikulincer and Shaver, 2010).
Priming is a form of implicit memory (Tulving & Schacter, 1990) where when one is exposed to stimulus and that exposure heightens the probability that it will positively influence responses at a later point in time. A common experiment illustrating priming will be to show subject a word, such as COMPUTER. At a later point, the subjects are shown the letters, COM and asked to complete the word. Those primed with the word COMPUTER are more likely, than those not primed with the word, to complete the word correctly. This theory explains how we learn things through exposure or observation. Repeated interactions with our early caregivers teach us “the how” of close relationships through implicit memory and priming (Stupica & Cassidy, 2014).
Secure base priming, specifically, is the activating of mental representations of attachment figures through words, images and guided imagery, symbolically making these persons available for soothing, reassurance and help. This process has been found to increase a person’s sense of felt-security, which contributes to emotional balance and flexibility, particularly when under stress. Priming can occur either subliminally (not conscious to the subject) or supraliminally (conscious to the subject).
Mikulincer and Shaver took the prototypical secure base script (Mikulincer, Shaver, Sapir-Lavid & Avihou-Kanza, 2009) and created both subliminal and supraliminal priming techniques to activate "secure base mental representations", of individuals assessed as having insecure attachment. Attachment style was measured by The Experiences in Close Relationship Questionnaire (Fraley, Heffernan, Vicary, & Brumbaugh, 2011). The prototypical secure base script is as follows:
“If I encounter an obstacle and/or become distressed, I can approach a significant other for help; he or she is likely to be available and supportive; I will experience relief and comfort as a result of proximity to this person; I can then return to other activities.”
From this script they created words, pictures and visual imagery exercises that they hypothesized would activate positive mental representations of attachment figures, and consequently cause insecure subjects to respond more like securely attached subjects. All subjects in their studies were primed subliminally or supraliminally and then subjected to their experimental conditions.
Mikuliner and Shaver hypothesized that their priming effects were changing secure base structures in the brain, which has been found to be the case in studies of secure base priming where brain imaging has been utilized to document the neurological basis of secure and insecure attachment (Gillath, Selcuk & Shaver, 2008; Canterberry & Gillath, 2012; Gillath, Adams, & Kunkel, 2012).
The Secure Base Primes
Mikulincer and Shaver structured their primes based on previous, effective priming techniques reported in the literature (2001). They utilized words (e.g., comfort, love, embrace, secure) images (e.g., mothers/fathers holding children, couples kissing/hugging, photographs of the research subject’s attachment figure; a Picasso painting of a mother and daughter) and visual imagery (prior actual secure base experiences and constructed) to prime their subjects. These primes are very reminiscent of what is typically done in psychotherapy to promote client change. Therapists:
- Utilize words to express love, caring and concern for their clients;
- They discuss positive outcomes that create positive associations in our client’s minds;
- They experientially give clients secure base experiences through their personal interactions with their clients (help solve problems and relieve distress);
- Encourage clients to create secure base experiences outside of therapy; and…
- Repeatedly prime their clients with these experiences every week, sometimes multiple times a week, over months and years.
So in a sense, clinicians are undertaking secure base priming with their clients. However, there are huge differences between temporarily changing attachment representations and/or affect in the laboratory, and doing so through live, in-person interactions with clients in the therapist's office. Psychotherapy outcome studies have repeatedly demonstrated that the strength of the therapeutic alliance is one of the most robust predictors of positive outcome in psychotherapy (Horvath, Del Re, Flückiger & Symonds, 2011). The role of the relationship with the therapist to therapy outcome cannot be under-estimated. Priming through an interaction with a computer will not be the same as a real relationship. But can it enhance the effects gained through a face-to-face relationship? As a practicing clinician, I can’t imagine that computer-based priming could ever replace a real relationship (such as in the movie, Her), but the former could enhance the later.
So a number of critical question come to mind.
- Presently the experimentally induced effects of secure base priming, though robust, only last a few minutes. Can the positive effects of secure base priming be strengthened through repeated priming experiences (Gillath, Selcuk & Shaver, 2008)?
- If so, how much priming is needed to obtain a lasting effect on personality and/or behavior? How many days a week are needed and for how long?
- Do these effects translate to behavior in the participant’s real-life relationships?
- How will these effects interact with psychotherapy if it is occurring simultaneously? Will therapy boost priming effects? Will priming dampen the therapy effects?
For possible answers to these questions we turn to the areas of neuroplasticity and brain training.
Today, consumers are being bombarded with information about how they can strengthen and/or change cognitive functions through "brain training" exercises. These claimed are based on the principles of neuroplasticity - that neural pathways and synaptic activity can be changed due to environmental influences. There is much data being published both promoting specific programs as well as examining overall outcome across brain training programs. The available data is very conflicting so that making an informed decision can be very difficult for the consumer (see internet links below).
I have been trained to administer one of these programs to older adults (Cogmed Working Memory Training by Pearson Assessments). I took the 5-week training myself to appreciate just what the experience is like for the consumer. This experience taught several things. First, I quickly learned why most people quit their training program before finishing it. Changing cognitive functions of the brain is not easy and you are likely to encounter many setbacks in the training process. I also discovered why there is such a high dropout rate with brain-training programs. Changing neurological function is not easy. It takes a lot of persistence and perseverance. Cogmed program has rigorous screening criteria and a coaching component. The coach checks in with the participant on a weekly basis and helps support users to finish the program in order to receive the most benefits. Because my wife was also training in using the program with children, we coached each other through the five weeks (five days a week, for 45 minutes) of training. Completing the program also helped me understand, how much effort is actually needed to change brain function so as to see real-world effects. It also reinforced the adage - use it or lose it. After the initial intensive training period, and a boost in working memory, I realized that periodic extension training was necessary for me to support the behavioral gains I experienced right after completing the intensive program.
The data suggests that “brain-training” is more successful when providers carefully choose their participants and provide client support. This is certainly true when choosing clients for psychotherapy treatment. A recent meta-analysis of studies looking specifically at working memory training programs, found mixed results in brain-training programs (Melby-Lervag and Hulme, 2013). For example, the researchers found more robust effects with younger children (under 10) than older children (over 10). They also found more robust effects with older adults (over 60) as compared to younger adults (under 60). Most notably, the researchers found that programs had better outcomes when they offered program support (coaching participants to complete the program), such as Cogmed. Besides the support component there were other variables that contributed to better outcomes such as economic, participant motivation, age, seriousness of impairment and other personality factors. For example, people who score higher on a measure of conscientiousness showed greater treatment effects.
Secure Base Priming as an Adjunct to Psychotherapy
If “brain-training” effectiveness may partly depend on careful screening and client support, it follows that the success of repeated secure base priming may also depend on these factors. Such a program would need clear screening criteria so that therapists could refer the most appropriate clients for priming. They could also provide the support and motivation for completing the exercises. In fact, clients could complete the priming exercises in their session (since they only take five to ten minutes to complete each day) and discuss their reactions with their therapist. This interactive process could augment the positive effects of psychotherapy.
If secure base priming techniques are similar to the naturally occurring psychotherapy process, and secure priming activates and strengthens attachment representations, and the neuroplasticity of the brain allows for such changes in secure base neurological function, then it stands to reason that repeated secure base priming can have persistent effects. Studies have documented the profound and persistent effects of mindfulness practice on brain structure and function (Urry, Nitschke, Dolski, Jackson, Dalton, Mueller & Davidson, 2004). For example, Davidson and his colleagues found that six days a week practice of mindfulness meditation, over two months, could dramatically change activation patterns in the prefrontal cortex; and continued practice will support these changes over time. Why can't repeated secure base priming do the same?
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