6Bruce Perry: The ChildTrauma Academy, 5161 San Felipe, Suite 320 Houston, Texas 77056 (also see B. Perry 2008, The Boy Who Was Raised as a Dog Basic Books)
7Affect regulationHow young minds form in thecontext of close relationships(Allan Schore)
8None of us in born with the capacity to regulate our own emotions. ATTACHMENTNone of us in born with the capacityto regulate our own emotions.The caregiver- child regulatory systemevolves where the infant’s signalsof changes in state are understoodand responded to by the caregiver,thereby becoming more regulated- co-regulation of affect.Peter Fonagy 2000
10The parents’ capacity to observe the child’s Sensitivity and mentalisationThe parents’ capacity to observe the child’smind seems to facilitate the child’sgeneral understanding of minds, andhence his/her self-organisation throughthe medium of a secure attachment.Peter Fonagy
11The child has the opportunity to ‘find Mentalisation: Peter Fonagy and Patrick Luyten 2009The child has the opportunity to ‘findhimself/herself in the other’ as someonewith thoughts and feelings - with a mind.The child recognises themselves and othersas intentional beings. Mentalisation isthe imaginative mental activity that enablesus to perceive and interpret humanbehaviour in terms of intentional mentalstates.Impairments in mentalisation play a role ina variety of psychopathologies of the self.
12Internal working model: cognition selfothersrelationshipnb Kenneth Craik (1943) andJ. Z. Young A Model for the Brain 1964.
13Patterns of attachment SECUREINSECUREorganisedINSECUREorganisedAVOIDANTAMBIVALENTINSECUREDISORGANISED
14Helpless/hostile caregiving The helpless stance involves failing to provide protection and regulation for the childHelpless states of mind - without strategies - a state in which the parent abdicates care and protection for the child, failing to terminate the child’s attachment system.Mentalisation goes ‘off-line’
15Helpless/hostile caregiving Feelings of fear, helplessness and hostility which result in frightening/ frightened behaviour might be the result of parents being unable to control frightening memories or emotions associated with their own childhood loss/traumas.
16Helpless/hostile caregiving Helpless states of mind - infant’s pain and fear evokes carer’s own past unresolved losses and fears + helplessness to know how to find comfort and safety.Carers find it difficult to hear, respond to and help modulate fear and distress in their child.Carers therefore both evoke fear in their children AND fail to recognise it.
17Disorganised/disorientated attachments: infancy Disorganised attachments arise when the attached infant has been alarmed by the parent rather than the external situation.The parent is experienced as:Frightening physically alarming/hostiledangerous parental behaviourFrightened psychologically alarmingparental behaviour/helpless
18DISORGANISED ATTACHMENTS Simultaneous activation of twoincompatible behavioural responses:FEAR and ATTACHMENT(avoidance) (approach)fear without escape; fright without solution.E. Hesse and M. Main
21Caregiving and disorganised attachments Physical, emotional and/or sexual abuse, including rejectionSevere neglect and deprivationMisuse/abuse of alcohol/drugsSerious affective disorder egdepressionUnresolved losses/childhood traumasDomestic violenceMultiple placements
22Disorganised attachments in young childhood ecological transactionsmediatorsAdult psychopathology
23Maltreated ChildrenMany abused and neglected children find mentalisation hard, particularly in interpersonal and intimate relationships because mentalising interactively is one of the most complex tasks.It is at these times that we are all vulnerable to hyperarousal and we need a buffer to protect us against overwhelming affect – it is mentalisation that acts as a cushion.Bateman and Fonagy 2004
24response: makes children aggressive, impulsive, needy, frightened. Maltreated ChildrenFor maltreated children, hyperarousal throws mentalisation ‘off-line’ – the result is panic, impulsive behaviour, fight-flightresponse: makes children aggressive, impulsive, needy,frightened.Under extreme trauma, a freeze-dissociative response is more likely.Bateman and Fonagy 2004
25Fearful and preoccupied attachments, emotionally For example, Borderline Personality Disorder:Fearful and preoccupied attachments, emotionallyneedy, feelings of being unloved and vulnerable,painful intolerance of aloneness, hypersensitivityto social environment, expectation of hostility fromothers, elevated rates of co-morbidity withdissociation, disturbed sense of identity, poormentalization, poor self-regulation, poor senseof self agency. Relationship chaos.Strong links with emotional neglect andemotional maltreatment in early childhood –child’s internal experiences not adequatelyrecognised, mirrored, enjoyed.
26executive (mentalising) to automatic (flight or fight) responding. Low arousal/stress threshold in the context of close relationships sees a switch fromexecutive (mentalising) to automatic (flight or fight) responding.Therefore low threshold of attachment system activation + simultaneousswitch to low mentalisation, both of which further intensify the relationship with the other.P. Fonagy and P. Luyten 2009: A developmental, mentalization-basedapproach…to BPD, Development and Psychopathology, 21, pp
27representations of another person’s We hypothesize that that the failure to think and reflect about self, others and feelings might leave the individual with difficulties in decoupling theirrepresentations of another person’sexperience from their own self-representations (reflected in terms of brain structures subserving the processes of knowing self and others).P. Fonagy and P. Luyten 2009: A developmental, mentalization-basedapproach…to BPD, Development and Psychopathology, 21, pp
28When mentalization fails, any sense of loss, rejection, abandonment or disinterestin the context of a close relationship feelscatastrophic. There is the constant dangerof being overwhelmed by the other’smental state. Psychic equivalence –subjective experience feels intensively real.Fight-flight responses.Emotional neglect + abuse/trauma:freeze, dissociative response (pretend modelosing connection with reality).
29Controlling ChildrenControlling strategies empower the child, allowing them to disown representations of the self as helpless, vulnerable and needing comfort - with this some degree of mental and behavioural coherence is achieved.However, when the child’s attachment system is strongly activated, this coherence is quickly destroyed: irrational, catastrophic, self-destructive ideationUnder such stresses, the fragile unitary representation of the self as ‘controlling’ is underpinned by a disorganised, dissociated iwm of self.
31Bowlby (1980) proposed 2 major defensive strategies: defensive exclusion, and‘segregation of principal systems.’Both have the effect of shutting available, but potentially anxiety-provoking, information out of awareness.
32Segregated mental systems is the more severe defence – it occurs when 2 or more selves are segregated from each other – walled off - each having access to its own sectionalised memory store or internal working model = dissociative processes, including DID.The selves can alternate in consciousness, but generally only one is dominant at any one time.
33Liotti, G. (2004). Trauma, dissociation, and disorganized attachment: three strands of a single braid. Psychotherapy: theory, research, practice and training, 41:
35Liotti also found that 62% of adults diagnosed with dissociative disorders had mothers who had lost a close relative within 2 years of their children’s birth. Similar risk also found if mother also suffered a traumatic experience within 2 years of child’s birth.
36PAST TRAUMA: afraid and alone Trauma and stress pile-up: Allen 2001PAST TRAUMA: afraid and aloneSensitised nervous systemCURRENT STRESS: reminders of traumaUnbearably painful emotional statesRETREATisolationdissociationdepressionSELF-DESTRUCTIVEACTIONSsubstance abuseeating disordersself-harmsuicidal ideationDESTRUCTIVEACTSaggressionviolencerages
37Bruce Perry: The ChildTrauma Academy, 5161 San Felipe, Suite 320 Houston, Texas 77056 (also see B. Perry 2008, The Boy Who Was Raised as a Dog Basic Books)
38behavioural and cognitive development social support and relationships Bottom-up, inside to outsideRespond to developmental age and not chronological ageRelationships as the most powerful of therapeutic experiencesbehavioural and cognitive developmentsocial support and relationshipspeer relationshipssocial cognition, understanding, empathymentalisation, play, attunement,affect regulationpredictability, repetition, routines, structuresafe and in controlmusic, movement and dancesensory integration treatmentsrocking, touch, massage
39The aim when working with parents is to help them develop their capacity forreflective functioning; to help themmentalise their own and their children’sexperience.It is difficult for children to change withouttheir environment also changing.
40When I work with a parent, I am trying to create a context in which he or she canslowly shift from a physical to a reflectiveor mentalizing stance. That is, I hold thechild in mind for the parent as a mentalizingbeing, as a person whose feelings andbehaviors are inextricably interrelated,and whose feelings and behaviors areinextricably intertwined with theirs as aparent. Most importantly, I see the child’sbehavior as meaningful.A. Slade (2008)
41Creation of space where the parent feels Working with parentsCreation of space where the parent feelsit is safe to mentalise, explore, name,and play with mental states – a playspace.2. Holding the parent in mind so that theparent can begin to hold the child in mind.3. Establish a working alliance in which theworker models the reflective stance inwhich the links between behaviour andmental states is constantly underscored.A. Slade (2008)
42The aim is to help parents enter their child’s experience as a means ofunderstanding them.Abusive parents tend to distort theirchild’s internal life and intentions –mis-attributions.Neglectful parents tend to block out,ignore and disconnect from their child’sinternal world resulting in a vacuousrelationship between parent and child.
43In order to understand parents’ intent, we will need to get ‘inside’ their adaptive strategies.That is, understanding how they develop overchildhood… we will need to think and feel likesomeone using their strategy if we are tounderstand parents who harm their children.Once we can do that, we may be able to joinparents meaningfully and guide them safely to aless dangerous reality. Without understandingthem as they understand themselves, we maynot be able to help.P. Crittenden 2008: Raising Parents, p 120
44Treatment needs to involve psychological and Transitional attachment figureOnce the parent sees or feels that the practitioner understands, the worker can act as a transitional attachment figure in the parent’s zone of proximal development.Treatment needs to involve psychological andbehavioural reorganisation, as opposed tosymptom reduction.
45Mentalization-Based Treatment (MBT) Focuses on the patient’s capacity tomentalize in the context of an attachmentrelationship.
46Clinical evidence suggests that as the MBTClinical evidence suggests that as theattachment bond between therapist andpatient intensifies, the quality of BPDpatient’s mentalization deteriorates.With BPD patients, beware treatments thatfocus on gaining insights into the traumaticpast high stress, hyperactivation of(fearfully preoccupied) attachmentsystem, non-mentalising stance,fight-flight-freeze responses.
47Child Abuse and Neglect attachment, development David HoweChild Abuse and Neglectattachment, developmentand interventionPalgrave/Macmillan2005