3ATTACHMENT CLASSIFICATION Adult attachment classification can be an important aspect of case formulationAttachment literature suggests in the context of the AIP model that patterns of attachment shaped in early caregiver experiences influence all later adaptive and maladaptive coping responsesDaniel Siegel (2010) : The best predictor of a child’s security of attachment is how his/her parents made sense of their own childhood experiences
4LIFE STORIESBy asking certain kinds of autobiographical questions, we can discover how people have made sense of their pastEach individual’s life story is defined by :The way we feel about the pastOur understanding of why people behaved as they didThe impact of those events on our development into adulthoodThis internal narrative may be limiting an individual in the present.
5LIFE STORIESParents who had a rough childhood and were unable to make sense of what happened would be likely to pass on that harshness to their own children who would in turn pass on this legacy to the next generationParents who had a tough time in childhood but did make sense of those experiences were found to have children who were securely attached to them : they had stopped handing down the family legacy of insecure attachment
6LIFE STORIESWhen taking a history, how an adult tells his or her story can be revealingSecurely attached people acknowledge both positive and negative aspects of family experiencesSecurely attached people can give a coherent account of their past and how they came to be who they are as adultsIn contrast, people who had challenging childhood experiences often have a life narrative that is incoherent
7LIFE STORIESWe can change our lives by developing a “coherent” narrative even if we did not start out with oneThrough EMDR treatment, and the AIP model, our clients who had difficult experiences early in life find a way to make sense of how those experiences have affected them and their current responsesThrough analysis of questioning in the Adult Attachment Interview, the AAI questions reveal an ‘adult state of mind’ with respect to attachmentA child’s attachment behaviour in childhood predicted the type of narrative developed as an adult
8CORRESPONDENCE OF ADULT AND CHILD ATTACHMENT ADULT NARRATIVEINFANT STRANGE SITUATION BEHAVIOURSecureDismissingPreoccupiedUnresolved/Dis-organisedSecureAvoidantAmbivalentDisorganised/Dis-oriented
9SECURE NARRATIVEMy Dad struggled to get a job and support us. He was irritable and often shouted at us. I didn’t feel close to him but my Mom helped me to understand how painful his situation was for us all. As I got older I felt sympathy for him, got over my anger and had a much closer relationship with him. It is easy for me to become emotionally close to others. I am comfortable depending on others and having others depend on me. I don’t worry about being alone or having others not accept me.
10DISMISSING NARRATIVEMy childhood was fine. My Dad was an accountant and my mother was an excellent normal mother. I had a normal childhood. In answer to specific questions, answers with ‘I don’t remember’ (cannot give details) I am comfortable without close emotional relationships. I like being on my own. It is very important for me to feel independent and self-sufficient, and I prefer not to depend on others or have others depend on me. Or ‘my parents were excellent parents. What’s all this got to do with the RTA?’
11PREOCCUPIED NARRATIVE My father was mad. He didn’t like me. He’d always say ‘don’t ever talk to me that way again’. And Mummy never said ‘don’t’ to him. (Talking as if parents were actually present). I want emotionally close relationships, but I find it difficult to trust others completely, or to depend on them. I worry that I will be hurt if I allow myself to become too close to others.
12PREOCCUPIED NARRATIVE OR I want to be completely emotionally intimate with others, but I often find that others are reluctant to get as close as I would like. I am not comfortable being without close relationships, but I sometimes worry that others don’t value me as much as I value them. I find it intolerable when people let me down.
13UNRESOLVED/DISORGANISED NARRATIVE At times I fall apart, so I can’t depend on myself. My child drives me crazy. I flip out whenever he gets upset. I feel like I m falling apart when he resists me. I feel like I become at first frightened and frozen, and then I’m afraid something will snap and I’ll scream or worse, I’ll hit him. I feel like I am losing my mind. Sometimes I just get stuck and I’m unable to move.
14UNRESOLVED/DISORGANISED NARRATIVE My Dad was scary. If I didn’t eat all my food he would scream at me and banish me to my room. Sometimes he would hit me with his belt. His face was very frightening when he was like that. Then later, he would come to my room and get into my bed and hold me and tell me he loved me. And I felt very good and safe in his arms.
15DAVID WALLIN, 2007 Secure/Autonomous Attachment Free to connect, explore and reflectAvoidant/Dismissive AttachmentNot-so-splendid isolationAmbivalent/Preoccupied AttachmentNo room for a mind of one’s ownDisorganised/Unresolved AttachmentScars of trauma and loss
16DIANA FOSHA, 2000 Secure Attachment Affective competence Feeling and dealing (while relating)Capable of auto- and interactive regulation‘I’m OK’
17DIANA FOSHA, 2000 Insecure Dismissive (Avoidant) Attachment Not Feeling but Dealing‘Goes on automatic’, eradicating feelings in order to cope.Less capable of interactive regulationI’m FINE, Really!’
18DIANA FOSHA, 2000Insecure Preoccupied (Ambivalent/Resistant) AttachmentFeeling but Not DealingBeing overwhelmed with feeling and unable to copeCapable of interactive regulation but not easily soothedLess capable of auto-regulation‘I’m dying, help!’
19DIANA FOSHA, 2000 Disorganised Attachment Not Feeling and Not Dealing Alternates between hyper- and hypoaroualNot capable of auto- or interactive regulation‘I’m not sure’
20ATTACHMENT CATEGORIES Research on attachment offers a powerful toolBut, each person is a one-of-a-kindHonouring uniqueness is essentialBut when we can ‘name it we can tame it’!
21POSSIBLE PROBLEMS CREATED BY ATTACHMENT PATTERNS IN EMDR PROTOCOL
22HISTORY TAKING : CLIENT’S COMMUNICATION SECURE clients communicateTruthfully and succinctly while remaining relevantTalk thoughtfully and with vivid affectAre capable, even when absorbed in strong feeling, of staying connectedAre mindful of the purpose of history takingTherapist feels connected with client and optimistic about treatment
23HISTORY TAKING DISMISSIVE clients : Have a hard time being coherent and collaborativeHave trouble being truthful, often failing to support, and may contradict, what they assertAre over succinct‘Don’t remember’ attachment-related experiences or needs for connection
24HISTORY TAKING DISMISSIVE clients Often have little to say about the difficulties that bring them to therapyThe past does not influence the presentDon’t need others for anythingOften come to therapy because partner thinks they have a problemCannot describe any situation from before turning, say, 15
25HISTORY TAKING DISMISSIVE clients : Express discomfort with history-takingTherapist feels frustrated as taking a history feel like pulling teeth and case conceptualisation becomes very difficult
26HISTORY TAKING PREOCCUPIED clients : May be truthful but are rarely succinctWhen asked about family patterns, they seem to unravel and become tangentialMay start to describe past situation and slip into what happened last weekCan easily become emotional and overwhelmed during history taking
27HISTORY TAKING PREOCCUPIED clients: Become preoccupied during history takingSuddenly the adult tone shifts into a desperately unhappy forlorn little boyTherapist feels swamped by client’s emotional responses during history taking
28HISTORY TAKING DISORGANISED clients, during history taking : May demonstrate sudden changes in speechOr fall silent for 2 minutes in mid-sentence and then continue on an unrelated topicMay give extreme attention to details surrounding lossIndicate that a deceased individual is simultaneously dead and alive
29HISTORY TAKING DISORGANISED clients May place the timing of an event, i.e. death, at several widely separated periodsMay indicate that they were responsible for the loss where no material cause is presentMay claim to have been absent at time of a traumatic event and then a bit later claim to have been presentMay describe an extremely traumatic event in flat tone and eerie detachment, when 5 minutes previously the client had been engaged and emotionally available
30HISTORY TAKING DISORGANISED client Therapist feels fragmented and unable to get a clear picture of client’s historyCase conceptualisation becomes a challenge!Creating a relationship in which the client can feel safe becomes a lengthy and fraught process
31PREPARATION PHASE SECURE clients : Can engage in the Safe Place exercise with easeGenerally do not need resource installation exercises as they are resilient enoughCan collaboratively select targets for EMDR processing with therapist
32PREPARATION PHASE DISMISSIVE clients : Generally reject Safe Place and RDI exercisesCannot self sootheDon’t allow anything ‘good’ to come their way from the therapistSP and RDI can lead to internal physiological distress or client reports no observable response
33PREPARATION PHASE DISMISSIVE clients Are either devaluing of resource workOr idealisingOr controllingTarget selection is thwarted by the client ‘not remembering’ any disturbance from the pastTherapist works hard to identify possible memories for targeting which are rejected as not eliciting any emotion by the client
34PREPARATION PHASE PREOCCUPIED clients Can work with Safe Place and RDI But choose a Safe Place with someone else looking after themMay become overwhelmed with sadness in their SP (I never got to feel this sense of security with my mother)Target selection becomes a challenge as too many memories of insecurity and cannot choose a touchstone eventPresent and past become entangled in target selection
35PREPARATION PHASE DISORGANISED clients Require lengthy preparation Could easily dissociate whilst doing the SP and RDI exercisesIf one ego states becomes relaxed in the SP, sabotaging or frightened parts could be in conflictRDI with unprepared ego states could also lead to conflict with other ego states
36PREPARATION PHASE DISORGANISED clients find target selection a huge challengeIdentifying certain targeted memories could destabilise ego states which are using denial as a way of copingTargets may also be relevant to one ego state and completely irrelevant to another ego state
37ASSESSMENT PHASE SECURE clients Have little or no problem with identifying the different elements comprising the basic protocolAre completely able to collaboratively identify the elements of the disturbing event with the therapist
38ASSESSMENT PHASE DISMISSIVE clients May thwart therapist’s attempts to find a positive cognitionSimilarly, the negative cognition never quite captures the feeling stateNo negative cognition is ‘good enough’As these clients ‘dismiss’ emotion, no NC will be acceptable, given that the NC is elicited to access the emotion inherent in the event
39ASSESSMENT PHASE DISMISSIVE clients Identifying the elements of the Assessment Phase and basic protocol could become a power struggle with the clientPC may be given a VOC of 7Wording used to elicit the NC could be a source of conflict and oppositionTherapist could end up feeling quite beleagueredBody sensation completely dismissed
40ASSESSMENT PHASE PREOCCUPIED clients Could find it hard to settle on one NC and one PCNC may spark a distressing feeling state, re-associating the client to the traumatic event too intensely leading to activation of dissociative defencesIdentifying the NC may be interpreted by client as the therapist abandoning themSUDs are often 20+ !
41ASSESSMENT PHASE DISORGANISED clients Identifying the baseline information in the Assessment Phase can trigger dissociationElements of Assessment Phase for one target may be very different for different ego statesCould go into a trance or become terrified
42PROCESSING SECURE clients Can usually process distressing material, thoughtfully, with appropriate emotions and physical sensations, making adaptive linksNeed limited intervention from the therapist in the form of therapeutic interweaves to reach adaptive resolution
43PROCESSING DISMISSIVE clients May struggle to get into a mindful state Answer ‘nothing’ to therapist’s question ; What do you notice now? Or ‘I’m just watching your fingers go back and forth’Need to be told exactly what they are ‘supposed’ to do‘I’m wondering if this is working‘Isn’t your arm getting tired?’‘This seems like a waste of time’
44PROCESSING DISMISSIVE clients If they access emotion, dismiss it : ‘well, isn’t that normal?’‘No I’m not doing well, I never have’Feedback very limited and briefTherapist not sure the material is processingSUDs do not decrease as little emotion is processed
45PROCESSING PREOCCUPIED clients Need constant reassurance and comfort of closenessHave chronically incomplete sessionsOften get stuck with high levels of emotion which does not resolveMove from one distressing incident/memory to the next without making adaptive linksHigh emotion may be a way of getting the therapist to intervene to take care of them
46PROCESSING PREOCCUPIED clients May process in a very detailed, tangential and fragmented wayChannels can slip from past to present with little coherenceCan become overwhelmed and helpless without resolution, and little adaptive response to cognitive interweaves offered by therapistEndless processing with little resolution
47PROCESSING DISORGANISED clients Processing is just that, disorganised Primary, secondary and tertiary dissociation to be expectedTherapist needs to work very hard to keep the client connected to present safetyExpect dissociation, projective identification and counter-transference
48EMDR / AIP MODELEMDR is so much more than an evidenced-based treatment for PTSD.The AIP Model explains why.Research and particularly ‘practice based’ research indicates that EMDR brings about symptom relief in a great number of distressing conditionsEMDR not only brings about ‘state’ changes but also ‘trait’ changes
49AIP and INTERNAL WORKING MODEL AIP has much in common with Bowlby’s Internal Working ModelBoth assert that early experiences drive perceptions and responses later in lifeBowlby stated that the child’s early experiences with attachment figures determined the child’s Internal Working Model, i.e. core beliefs about self, others and the world
50DIAGNOSIS : ATTACHMENT No all-encompassing diagnosis for adults affected by severe attachment-related traumaAttachment disorganization in adults is identified by disorientation, poor logic and extreme behavioural effects related to caregiver abuse or major loss‘Complex Trauma’ is not a formal diagnosisBut outlines the complexity and severity of symptoms in adults suffering from chronic abuse by attachment figures
51HYPOTHESIS?Can EMDR treatment focussing on early attachment-related trauma change the attachment status in the affected adult or child?If EMDR can successfully reprocess mal-adaptively stored distressing memories and create new adaptive associations in the brain, then targeting early attachment-related memories with EMDR should have a positive impact on the individual’s Internal Working Model
52HYPOTHESISThus, improvement of attachment status through EMDR treatment shouldhelp adult clients to function more adaptively in relationshipsand respond more sensitively to their children
53WESSELMANN & POTTER (2009)3 case studies illustrating pre- and post- EMDR adult attachment status as measured by the AAI (Adult Attachment Interview)All 3 categorised with an insecure or disorganized attachment status at pre-treatmentMood and anxiety symptoms related to problems in current marital and family relationshipsReceived 10 – 15 EMDR sessions utilising all 8 phasesFollowing EMDR treatment, all made positive changes in attachment status
54MADRID (2007)Describes a method of using EMDR to repair maternal-infant bonding failuresCase of a mother of a 5 year old girl who reported only negative emotions re her experience of being a mother : ‘She drains me, she’s a pest’Early negative bonding experiences identifiedStandard EMDR protocol used to desensitize and process these experiencesMother reported only positive feelings towards daughter
55CASE : ANNIE30 year old woman with extreme anxiety about 8 month old baby. Worries about the baby stopping breathing, that the baby will die and it will be her fault. Feels she is a terrible mother. She has found the last 8 months ‘too much’ and at times wishes she was not around.After 5 EMDR sessions says :“I am so much more positive now and have gained a much clearer sense of who I am, and importantly of how my interactions with the world are shaped. I know I’m an OK mom, I’m a good enough partner, and if I think I’m not, I really know why I think this. I feel so good about sharing my daughter’s ups and downs with her and just being there for her in a way I never thought was possible”Sent a picture of baby with card saying “We are both doing very well these days!”
56EFFECTIVENESS OF EMDR ON ATTACHMENT SECURITY Recent studies provide preliminary evidence that clients who lack adequate emotional regulation skills and social supports can, with support and preparation, and EMDR treatment :Resolve attachment injuriesImprove attachment statusImprove emotional stabilityImprove present day relationships
57EFFECTIVENESS OF EMDR ON ATTACHMENT SECURITY More randomized controlled studies are needed to evaluate changes following EMDR in adults and children who have experienced early relational traumaWesselman (2012) indicates that more research is needed to examine effects of EMDR onAttachment statusRelationship stabilityEmotional regulation, self-concept, beliefs and expectationsAnd Interpersonal behaviours and functioning
58EFFECTIVENESS OF EMDR ON ATTACHMENT SECURITY Wesselman :“If continued research finds EMDR an effective method for improving attachment status, it seems reasonable to expect that change in attachment status in parents may increase attachment security and organization in their children.”
59CASE : ADAM 2nd of 4 children When 3 sent with sister and brother to live with grandmother in Glasgow as parents couldn’t cope8 years taken with sister and brother to London (not told where going) to a home for boys and girlsSuffered physical, verbal and sexual abuseDoesn’t feel much about his experience and ‘just got on with it’Became a successful lawyerHas difficulty in relationships with women. Started a new relationship and really wants to make this one last
60ADAM Abandoned by parents Attached to grandmother but she abandoned the children by sending them to a homeAvoidant/dismissive attachment styleSecondary and some tertiary dissociationHas black rages with womenTarget : Rejection by teenage son NC :I’m invisibleFloatback : Waiting (over 3 hours) for father to collect him and brother and Kings Cross Station 11years
61ADAM Incredulity ……. Just waiting Waiting. Looking at that boy. How strange they look. Dressed in horrible thick short trousers and grey scratchy shirts and big badly fitting bootsThey look hopeless. No life about themTherapist : ‘Sitting in this chair, the adult you are today, can you just look at that child’YesTherapist : ‘Just see this child, just notice whatever you see (BLS)I can’t look at that child. Pathetic!Therapist : ‘What’s good about not looking at that child?’
62ADAM I don’t have to see his fear, I don’t want to see his fear (BLS) Well, I can look at him now’Therapist : ‘When you look at the child, can you see the child’s feelings?’He doesn’t have feelings, he’s not looking at me. (BLS)He’s not looking, not communicating (BLS)He’s not anxious to connect at all, he’s just closed (BLS)
63ADAMNot anxious at all if he is collected or not, so what (BLS) So what. Voice is distant, a monotoneTherapist asks the client to come back to the room (CIPOS) (BLS) ‘Come back to the room, We’ll get back to that boy at the station is a minute. But right now come back out of it to the room’ (BLS, bringing him back into therapy room)‘OK, when you’re ready, close your eyes and just be drawn back to the boy at the station again. But let yourself be sure to stay partly here. Just look at that child, that boy, just see and notice whatever you see (BLS)I feel irritated with him, I can’t understand why he does not ask someone, find out what’s happening (BLS)
64ADAMFeeling twitchyTherapist invites client to come back to present safety, then back to the child. ‘Just look at that child. Is there anything that you know as an adult, that would be helpful to that child?’(long pause) I don’t know, I don’t know how to comfort him, to get in. I can’t look at him.Therapist : ‘What’s good about not looking at him?’I can’t bear his loneliness, his hopelessness (BLS)I feel sad for that boy …. (becomes a bit tearful) (BLS)
65ADAMTherapist : When you see this child, if you could go back in time, the man you are today, and go to that boy and tell him something that would help him with his sadness, something you know that he doesn’t know, that would really help him, what would you say to him?’I could tell him he deserves better. That he will be OK (BLS)Therapist : Do you think that boy has it rough?’Yes, yes, I do think he has it rough (BLS)Therapist: When you look at this boy, how do you feel about him when you think of this?’I feel sad for him because he has no-one taking care of him (BLS)
66ADAM He has good reason to feel frightened, even angry (BLS) I would never treat my boy, my son like that (BLS) Tearful.In this way, the therapist assists the client in strengthening the part of the self that is oriented to present reality, and then assists that present-oriented ego state in witnessing the painful affect held in a dissociated child ego state. Often the affect within a child ego state has never been compassionately observed, either by another person, or by another part of the self within the personality system