I had the good fortune recently to participate in a think tank and conference in The Netherlands with Jim Coan, a talented clinical psychologist at the University of Virginia who is conducting pioneering neurobiological research on attachment. I think the results of his research have profound implications for stress management and for treatment; I inform patients about his work every chance I get.

Clever experiment

Jim and his colleagues¹ conducted a remarkably clever experiment with married couples published with the inviting title, “Lending a Hand.” The couples were carefully selected to be highly satisfied in their marriage. In the experiment, the women were exposed to a stressful situation: They had electrodes fastened to their ankles and periodically were given electric shocks. Before the shocks, they were given one of two signals:

1. a safety signal indicating that they would not be shocked or 
2. a threat signal indicating that there was a 20 percent chance of being shocked (and they were shocked on some trials).

This procedure enabled the researchers to compare patterns of the women’s brain activity (with functional magnetic resonance imaging) under two conditions:

1. when they were feeling threatened versus 
2. when they were feeling safe.

Here is the clever part: at different points during the threatening procedure, the women were permitted to hold their husband’s hand, a stranger’s hand or no one’s hand. Also of interest, even though these couples were highly satisfied with their relationship, the researchers assessed differences in degree of satisfaction within the group (i.e., more satisfied or less satisfied). These differences make a difference.

Complex results

The details of the findings are complex, as the researchers studied more than a dozen different areas of brain activity. In broad terms, they studied activity in areas that indicate emotional response to threat as well as areas that are known to regulate or control emotional distress. Complex as they may be, the gist of the findings is elegant and important: the more the woman was on her own while she was feeling threatened, the greater the number of brain areas showing elevated activity. The brain was least active when the woman was holding her husband’s hand and most active when she had no hand to hold. Moreover, even though all couples had a good relationship, the women who were in a less satisfying relationship showed more elevated brain activity when holding their husband’s hand than those who were in a more satisfying relationship.

Efficient distress management

Jim came to a simple conclusion: When we are threatened, a feeling of connection with a person to whom we are securely attached is our most efficient way of regulating distress. His social baseline theory² proposes that we humans are hard-wired to use social proximity as a default strategy for regulating emotional stress. He also notes that we share this default strategy with many other mammalian and bird species. This strategy evolved not only because there is safety in numbers but also because reliance on trusted companions for help and support lessens the load on our individual resources. True, we must learn to manage distress on our own to a considerable degree. Ironically, one of the best ways to cope with emotion is to be tolerant and accepting of emotional distress; fighting it makes it worse.³ But the experiment’s results demonstrate clearly that managing on our own—however we may do it—is a costly strategy; it is effortful. Attachment can cut off stress at the pass. Mere proximity to another person in a threatening situation is of some help, but proximity to a familiar person is more help and proximity to a trusted attachment figure is most helpful.

Extensive neuroimaging research shows that the prefrontal cortex plays a major role in regulating stress. The prefrontal cortex also uses a great deal of energy. Hence we can conserve energy by relying on attachment relationships—to use an apt economic metaphor, we “outsource” stress regulation to our social networks.⁴ This attachment strategy frees up brain resources to engage in problem solving: We have more capacity to deal effectively with the source of threat if we don’t have to invest so much energy in regulating our distress. Being more accepting of stress rather than trying to suppress it might be one way of conserving some energy. But attachment is another. Yet there is a caveat: The attachment strategy works best when the partner is emotionally attuned, as partners in highly satisfying marriages are likely to be. Seeking comfort from someone to whom you are insecurely attached is liable to increase stress.⁵

It’s best to let Jim speak for himself; he neatly summarizes his thinking as follows: 

The social baseline model proposes that social forms of emotion regulation are not ‘down-regulatory’ in the same sense as self-regulation efforts. Rather, it proposes that social resources alter perception-action links associated with intervening in the environment, such that there is less perceived alarm when perceived social resources are high, which corresponds in turn to fewer actions needed to meet demands associated with the stressor. This, I have argued, conserves metabolically costly operations in the prefrontal cortex and elsewhere, either by simply conserving neural resources or freeing them to be devoted to other problems, thus increasing the efficiency of coping with a potentially dangerous and uncertain world.^{2(p. 620)} 

Implications for practice

I find especially provocative a point he⁶ makes about the implications of this theory and research for clinical practice. We put a lot of effort into developing treatment methods to help patients become more adept at self-regulation of emotions. Prominent examples include mindfulness practice,⁷ dialectical behavior therapy⁸ and cognitive-behavior therapy.⁹ No doubt, we all need to be adept at self-regulation; we can’t be holding our attachment figure’s hand whenever we feel threatened! Yet self-regulation is not the most efficient or powerful means of emotion regulation. Accordingly, we should be putting as much—or more—effort into developing treatment approaches that enhance attachment relationships and promote security in those relationships.

In the past decade, considerable effort has gone into applying attachment theory and research to psychotherapy.^10-14 Yet, now buttressed by Jim’s research, Sue Johnson^{15, 16} has made a compelling case for working on attachment relationships directly in marital, couples and family therapy to enhance emotional connection and security—handholding that works. Thanks to evolution, we have a remarkable ability to rely on attachments to manage stress by merely feeling connected. My advice: Strive to develop, maintain and make full use of secure attachment relationships, and give your overworked brain a break—and your body as well, given the toll stress takes on your health. 

References 

1. Coan JA, Schaefer HS, Davidson RJ. Lending a hand: Social regulation of the neural response to threat. Psychological Science. 2006; 17:1032-1039.
2. Coan JA. The social regulation of emotion. In: Decety J, Cacioppo JT, eds. Handbook of social neuroscience. New York: Oxford University Press; 2011:614-623.
3. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford; 1999.
4.  Coan JA. Adult attachment and the brain. Journal of Social and Personal Relationships. 2010; 27:210-217.
5. Mikulincer M, Shaver PR. Attachment in adulthood: Structure, dynamics, and change. New York: Guilford; 2007.
6. Coan JA. Toward a neuroscience of attachment. In: Cassidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and clinical applications (Second Edition). New York: Guilford; 2008; 241-265.
7. Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Delta; 1990.
8. Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford; 1993.
9. Barlow DH, Allen LB, Choate ML. Toward a unified treatment for emotional disorders. Behavior Therapy. 2004; 35:205-230.
10. Allen JG, Fonagy P, Bateman A. Mentalizing in clinical practice. Washington, DC: American Psychiatric Publishing; 2008.
11. Holmes J. Exploring in security: Towards an attachment-informed psychoanalytic psychotherapy. New York: Routledge; 2010.
12. Obegi JH, Berant E, eds. Attachment theory and research in clinical work. New York: Guilford; 2009.
13. Slade A. The implications of attachment theory and research for adult psychotherapy: Research and clinical perspectives. In: Cassidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and clinical applications (Second Edition). New York: Guilford; 2008; 762-782.
14. Wallin DJ. Attachment in psychotherapy. New York: Guilford; 2007.
15. Johnson SM. Couple and family therapy: An attachment perspective. In: Cassidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and clinical applications (Second Edition). New York: Guilford; 2008; 811-829.
16. Johnson SM, Courtois CA. Couple therapy. In: Courtois CA, Ford JD, eds. Treating complex traumatic stress disorders: An evidence-based guide. New York: Guilford; 2009; 371-390.

Tagged as: attachment, cognitive-behavior therapy, dialectical behavior therapy, distress, emotional, mindfulness, prefontal cortex, regulate, relationships, research, satisfaction, social baseline model, stress, therapy, threat, treatment