1. Overcoming Attachment Problems A workshop delivered by Secure Start Principal Psychologist Colby Pearce 21 June 2011, Adelaide Meridien  Secure Start ® 2011

2. Introduction Colour My Life (Hall et al., (2002). Fifteen Effective Play Therapies. Professional Psychology: Research and Practice,33 (6), 515-522)

3. Case Example: John John was a superficially charming fourteen-year-old lad with bright red hair and a ready smile. I met John soon after I began my first appointment as a Clinical Psychologist in 1995. John was a Ward of the State. He was referred to me because statutory social workers who were responsible for his care were concerned about his volatile and at-risk behaviours. John had made a number of suicidal gestures, was often AWOL from the facility at which he resided and was known to abuse substances. John was also suspected of being involved in child prostitution. He once asserted that he was not gay and that “it” (prostitution) was just “business”.

4. Attachment Representations (Pearce, C.M. (2010). An Integration of Theory, Science and Reflective Clinical Practice in the Care and Management of Attachment-Disordered Children – A Triple A Approach. Educational and Child Psychology (Special Issue on Attachment), 27 (3), 73-86) I am: Bad  Unlovable  Impotent Others (are):  Unreliable  Unresponsive  Uncaring The world is:  Unsafe I am:  Good  Deserving  Capable Others are:  Understanding  Responsive  Accessible The world is:  Safe Attachment-disordered Insecure/Unsure Secure (Manipulative/Controlling) (Tests the limits) (Expectant) Attachment security and representations regarding self, other and world (Adapted from Pearce, 2009) Negative AttachmentPositive Attachment RepresentationsRepresentations

5. A Tale of Three Mice Source: Pearce CM (2009), A Short Introduction to Attachment and Attachment Disorder. London: Jessica Kingsley Once upon a time there were three mice. The first mouse lived in a house that contained, along with furniture and other household goods and possessions, a button and a hole in the wall from which food was delivered. Each time the mouse pressed the button he would receive a tasty morsel of his favourite food. The mouse understood that, when he was hungry, all he had to do was press the button and food would arrive via the hole. The mouse took great comfort in the predictability of his access to food and only pressed the button when he was hungry. The second mouse lived in a similar house, also containing a button and a hole in the wall from which food was delivered. Unfortunately, the button in his house was faulty and delivered food on a inconsistent basis when he pressed it, such that he might only receive food via the hole on the first, fifth, seventh, or even the eleventh time he pressed the button. This mouse learnt that he could not always rely on the button and that he had to press the button many times, and even when he was not actually hungry, in order to ensure access to food. Even after his button was fixed he found it difficult to stop pressing it frequently and even displayed a habit of storing up food. The third mouse also lived in a similar house, containing a button and a hole in the wall from which food was to be delivered. However, the button in his house did not work at all. He soon learnt that he could not rely on the button and would have to develop other ways of gaining access to food. This belief persisted, even when he moved to a new home with a fully-functioning button.

6. Patterns of Arousal and Overarousal (Pearce, C.M. (2010). An Integration of Theory, Science and Reflective Clinical Practice in the Care and Management of Attachment-Disordered Children – A Triple A Approach. Educational and Child Psychology (Special Issue on Attachment), 27 (3), 73-86) Anxiety Threshold Attachment- disordered Child Secure Child Anxiety/Hyper-arousal (Psychologically Unsustainable) Fight-Flight-Freeze Arousal Reduction Time Arousal Lowered Perception of threat

7. What does attachment disorder look like? (Source: Pearce, C. (2009). A Short Introduction to Attachment and Attachment Disorder. London: Jessica Kingsley) CharacteristicManifestations Maladaptive Perceptions of Self Poor Self-Concept Poor Self-Care Bodily Function Disturbances Low Expectations of Deservedness (e.g. wetting, soiling) Maladaptive Perceptions of other Avoidance of Engagement/Intimacy Lack of Empathy Habitual Mistrust Superficial Charm Maladaptive Perceptions of the Social World Preoccupation with Safety Preoccupation with Fairness Preoccupation with Rules Preoccupation with Consistency Preoccupation with Knowing Hyperarousal (Anxiety) Aggression Hyperactivity Destructiveness Inattention Dissociation Emotional Lability (Instability) Watchfulness/Hypervigilance Developmental/Learning Problems/Delays Preoccupation with Accessibility to Needs Provision Controlling Demanding Manipulative Charming Deceitful

8. What is Attachment? Attachment is the term used for the special relationship children develop towards their primary caregivers during infancy. It is special because these are the people the infant learns to trust and depend upon to look after them. It is also special because infants expect other adults in a caregiving role to be like their primary caregivers. That is, attachment relationships formed in infancy directly influence the child’s expectations about all other interactions and relationships with others.

9. Types of Attachment Secure Insecure-Avoidant Insecure-Ambivalent Disorganised/Disoriented

10. Aspects of parenting that influence attachment Source: Pearce CM (2009), A Short Introduction to Attachment and Attachment Disorder. London: Jessica Kingsley Accessibility Understanding and Responsiveness Affective Attunement and Affect/Arousal Regulation

11. Individual and lifestyle factors that impact on caregiving and attachment Parental mental health problems Parental substance misuse Domestic violence Poor parenting ability/knowledge Insecure attachment as a child

12. A Triple-A Approach Addresses: Attachment Representations Accessibility to Needs Provision Arousal

13. A Triple-A Approach (Pearce, C.M. (2010). An Integration of Theory, Science and Reflective Clinical Practice in the Care and Management of Attachment-Disordered Children – A Triple A Approach. Educational and Child Psychology (Special Issue on Attachment), 27 (3), 73-86) Hyper-Arousal (Affect Dysregulation) Insecure Attachment Representations (Negative Perception of self and other) Preoccupation with Accessibility to Needs Provision Behaviours and affective displays associated with the fight-flight- freeze response, resulting in conflict with others Diminished trust in others Diminished expectations of deservedness Anxiety The Aetiology of Maladjustment

14. Changing Attachment Representations Also involves: Enriching Understanding Enriching Accessibility Enriching Attunement and Affect/Arousal Regulation

15. Enriching Understanding: Self-Fulfilling Prophesies Thought/Belief Feeling Behaviour Reaction

16. Example of a self-fulfilling prophesy I am Bad Anger Hitting, Yelling, Breaking Reprimand / Discipline

17. Circumventing self-fulfilling prophesies (Pearce, C.M. (2010). An Integration of Theory, Science and Reflective Clinical Practice in the Care and Management of Attachment-Disordered Children – A Triple A Approach. Educational and Child Psychology (Special Issue on Attachment), 27 (3), 73-86) I am Bad Anger Hitting, Yelling, Breaking Understanding / Need Provision

18. Respond to the need as well as the behaviour (Pearce, C.M. (2011). A Short Introduction to Promoting Resilience in Children. London: Jessica Kingsley) BehaviourPossible Explanation NeedHelpful Responses Unhelpful Responses Child refuses to stay in their bed Separation anxiety and/or insecurity Reassurance that the caregiver is aware of them, accessible and responsive Remain Calm. Engage in soothing bedtime rituals. Checking back in with the child before they get out of bed to achieve proximity to the caregiver Parental Anger and frustration. Disciplining the child. Ignoring the child. Child becomes overly loud and boisterous at a family function. Child is overstimulated Soothing and/or opportunities to blow off steam Temporarily withdrawing the child from the stimulating environment in order to calm/soothe them or provide a release Yelling at the child to “calm down”

19. Verbalising Understanding (Pearce, C.M. (2011). A Short Introduction to Promoting Resilience in Children. London: Jessica Kingsley) BehaviourPossible Reason Example of an unhelpful or ineffective response Example of an Understanding response Example of an effective management response Child sneaks food from the cupboard Hungry Concerned others will eat first Admonishment and restriction of access to food I think you must have been hungry I think you were worries that [others] might eat them all before you did. Make it a rule that the child must ask for snacks Divide the available snacks equally into separate containers for each child of the household Child hits another child Other child hit first Anger and disapproval They must have done something to make you feel really angry Next time someone does something that makes you feel really angry you should...

20. Enriching Accessibility Source: Pearce CM (2009), A Short Introduction to Attachment and Attachment Disorder. London: Jessica Kingsley Verbalising Understanding: I think that you believe that I will forget about you if we are not always together. I think that you believe I won’t notice or understand when you really need me/something. You believe that if I don’t do it [get it for you] now I will forget. You worry that I won’t come back for you. You worry that I don’t like you anymore. You know you have done something wrong and you worry that I won’t like/love you anymore.

21. Enriching Accessibility Source: Pearce CM (2009), A Short Introduction to Attachment and Attachment Disorder. London: Jessica Kingsley Emotional Refuelling (in reverse)

22. Enriching Attunement (Pearce, C.M. (2011). A Short Introduction to Promoting Resilience in Children. London: Jessica Kingsley) Empathy (In order to be heard we first need to listen)

23. Addressing Accessibility Preoccupations Managing Emotional Connectedness Consistency and Predictability

24. Addressing Arousal (Pearce, C.M. (2011). A Short Introduction to Promoting Resilience in Children. London: Jessica Kingsley) The Mozart Effect and the role of Music

25. Attachment Therapy: The Role of Play Engagement Therapy is more likely to be beneficial when children and adolescents are willing participants. Most children and adolescents are reluctant, at-least initially, to attend and be involved in therapy. Either they don’t know what to expect, which causes anxiety, or they think that they have to attend because they have been “bad”. However, almost all children and adolescents enjoy playing and engaging in fun activities with a lively adult. So, incorporating fun activities into psychotherapy is a good way to help children and adolescents feel relaxed about attending therapy and, indeed, increases their motivation to attend.

26. Attachment Therapy: The Role of Play Making and maintaining a connection Research has found that the heart rates of mothers and children parallel each other during play. Heart rate is a sign of the level of activity of the nervous system, which we call arousal. Arousal is one of the two components of emotion. So, during play, adults and children are emotionally-connected to each other.

27. Attachment Therapy: The Role of Play Encouraging self-regulation Most children and adolescents who are referred for therapy because of attachment problems have trouble controlling their emotions, their behaviour, or both. The ability to self-regulate emotions and behaviour is thought to develop from adult caregivers providing a range of emotional experiences and intervening to ensure that children do not become overly excited or overly distressed during their early development. So, we utilise play and the emotional connection associated with play to develop the child or adolescent’s capacity for self-regulation by facilitating the experience of a range of emotions of varying intensity and returning them to a state of calm.

28. Attachment Therapy: The Role of Play Affirmative Experiences Children and adolescents with attachment problems who are referred for therapy hold negative beliefs about themselves, about others and about the world in which they live. Simply telling children that they are good, that others are caring and understanding, and that the world is a safe place is rarely effective in changing children’s beliefs. Rather, they need to experience themselves, others and their social world differently. During therapeutic play, children and adolescents experience themselves as likeable and capable, experience others as fun and “nice”, and their world as safe and a source of happy experiences. This facilitates trust in others and the perception that therapy is a safe place for conversation about the reasons for their emotional distress and/or maladjusted behaviour.