Presentation on theme: "Attachment and Related Disorders"— Presentation transcript:
1Attachment and Related Disorders Barbara Morrell, Ph.D.Brigham Young UniversityInservice Presented to Counseling and Career CenterJanuary 13, 2005
2AttachmentThe attachment relationship between parent and child refers to those aspects of the relationship that serve to regulate the infant’s stressful arousal or sense of felt security. The quality of regulation of fearful affect available in attachment relationships is foundational to the developing child’s freedom to turn attention away from issues of threat and security toward other developmental achievements such as exploration, learning, and play.
3Attachment Theory John Bowlby (1969): Attempt to bridge psychological and biological developmentRejected Freud’s view that libidinal tie to the mother for need satisfaction is primary.Instead, relationship (binding infant to mother and mother to infant) is primary.Secure attachment to mother essential to normal brain development and relational development
4Bowlby:As in biological development, role of mother is central to child development:“ If growth is to proceed smoothly, the tissues must be exposed to the influence of the appropriate organizer at certain critical periods. In the same way, for mental development to proceed smoothly, it would appear to be necessary for the undifferentiated psyche to be exposed during certain critical periods to the influence of the psychic organizer—the mother [or other caregiver].”
5Testing Attachment Theory Mary Ainsworth: Strange SituationChild is observed for 20 minutesCaregivers and Strangers enter and leave the roomRecreates the flow of familiar and unfamiliar presence in most children's’ livesThe situation varies in amount of stress, and child’s responses are observed
6Bowlby (1969)Mother-infant attachment communications are “accompanied by the strongest of feelings and emotions, and occur with a context of “facial expression, posture, tone of voice, physiological changes, tempo of movement, and incipient action”.
7Attachment and Neurobiology Ovtscharoff & Braun (Neuroscience, 2001)“ the dyadic interaction between the newborn and the mother… serves as a regulator of the developing individual’s internal homeostasis. [This] may be an essential promoter to ensure the normal development and maintenance of synaptic connections during the establishment of functional brain circuits.”
8Attachment and Neurobiology Fonagy and Target, 2002“Attachment relationships are formative because they facilitate the development of the brain’s self-regulatory mechanism.”Helmeke et al, Cerebral Cortex, 2001“The functional maturation of limbic circuits is significantly influenced by early socio-emotional experience.”
9Attachment and Neurobiology Ainsworth (1967)Attachment is “being built into the nervous system, in the course and as a result of the infant’s experience of his transactions with the mother”
10Impact of Attachment on the Brain Helmeke et al, (Cerebral Cortex, 2001)“Positive or Negative emotional experience may carve a permanent trace into a still developing neuronal network of immature synaptic connections, and thereby can extend or limit the functional capacity of the brain during later stages of life.”
11Neurobiology of Development : Role of the Right Brain Affect Regulation (limbic system) is located in the Right Hemisphere of the BrainBrown and Jaffe, 1975:The right hemisphere can be considered dominant in infancy, for the type of visual and acoustic communication which is relevant for the prelinguistic child.”Matsuzawa et al, Cerebral Cortex, 2001:Infants under 2 years higher right than left hemisphere volume.
12Right Brain cont.Right Hemisphere stores a vocabulary for nonverbal affective signals such as facial expressions, tone of voice, and gestures.RH function: self-regulation—ability to resiliently regulate emotional states in interaction with others..
13Mother-Infant Communication Transactions happens Right Brain to Right Brain80% of Right and Left-handed mothers cradle infant in left arm—easier access to left ear and face (right brain)Schore (1994)“During eye-to-eye transactions the infant’s maturing right hemisphere is ‘psychobiologically attuned’ to the output of the mother’s right hemisphere”
14Attachment, Neurobiology, & Self Allan Schore (2003)“Attachment bonding is critical to development of the right brain systems involved in processing emotion, modulation of stress, self-regulation, and the early origins of the bodily-based implicit self.”RH Development = Beginnings of the Self?“By casting the Right Hemisphere in terms of self, we have a revolutionary way of thinking about the brain” (Keenan, 2003).
16Neurodynamics and Psychodynamics Poeggel et al (Neuroscience, 2000)“Neurodynamics parallel psychodynamics in the sense that the disruption of attachment bonds at very early stages of life leads to a regulatory failure and an impaired brain homeostasis.”
17Mother vs. Father in brain regulation development Schore:Mother is major regulator for brain growth in 1st year of life.Father major during second year.(lack of attachment research on Fathers and infants)
18Implications for Psychological Development SchoreAttachment Theory is fundamentally a theory of the intersubjective origins of the selfSelf-organization occurs in context of a relationship with another self, another brain.Devinsky (Epilepsy and Behavior,2000)RH is dominant for “maintaining a coherent, continuous and unified sense of self.”Through constant interactions from birth, caregiver is a mirror for child to understand self
19Attachment Styles Organized Attachment Disorganized Attachment Secure Anxious-Ambivalent InsecureAnxious-Avoidant InsecureDisorganized AttachmentLack of coherent style at monthsLeads in later years to:Controlling/Caretaking Relationship PatternControlling/Punitive Relationship Pattern
20Secure Attachment Behaviors in Strange Situation Explore freely while mother presentEngage with StrangersVisibly upset when mother departsHappy to see mother return
21Secure AttachmentHappens when the mother is available and able to meet the needs of the child in a responsive and appropriate manner for the particular childAccurate mirroring of infant’s nonverbal cues from birthResponding to stress signals and giving helpful assistanceSecure base from which to exploreUnder stress, when appropriate assistance is given, educates the child in how to cope with problems in the future.Mother’s emotional response helps infant regulate own emotions (becomes wired)
22Development of Mentalization Peter Fonagy (2005)For normal development the child needs to experience a mind that has his mind in mindAble to reflect on his intentions accuratelyDoes not overwhelm himNot accessible to neglected childrenMentalizationCapacity for affect regulation and a reflective functionForm of imaginative mental activity:Perceiving and interpreting human behaviors in terms needs, desires, feelings, beliefs goalsIn stressful situation can see self being active and effective: example—5yr old puts trampoline under World Trade Center in his picture after 9/11
23Anxious-Ambivalent Insecure Behaviors Anxious of exploration and strangers even when mother presentExtremely distressed when mother departsClings to mother when she returns, but seems resentfulResistant when mother initiates attention
24Anxious-Avoidant Insecure Behaviors Avoid or Ignore mother when she is in roomShows little emotion when mother departs or returnsDoes not explore muchStrangers treated same as motherShows little emotional range
25Parenting Syles in Insecure Attachment Anxious-Ambivalent InsecureMother is engaged, but on own termsInfant’s needs ignored until some other activity is finishedAttention given more through needs of parentAnxious-Avoidant InsecureMother is more disengagedChild’s needs frequently not metChild believes communication has no influence on mother
26Disorganized Attachment Behaviors First identified at 12 months of ageErratic BehaviorsFreezingHuddling on floorSlowed (under water-like) movements in presence of caregiver when under stressDisoriented:WanderingConfused, dazed expressionIn combination with secure strategiesprotesting separationSeeking reunion at return of motherCeasing distress when picked upKey is “No Coherent Strategy”
27Disorganized (Type D) Parenting Styles Parental WithdrawalNegative-intrusive responsesRole-confused responses (seeking comfort from child, etc)Disoriented responses (Dissociation, drug abuse, etc)Frightened or frightening responsesContradictory responses or failure to respond to infant signals
28Costs of Disorganized Attachment Loss of Behavioral ControlExperience of unresolved helpless, fearful, or angry affectsProlonged cortisol elevations“If child uses caregiver as a mirror to understand the self, the disorganized child is looking into a mirror broken in a thousand pieces.”
29Animal Studies of Attachment Macaques:Offspring of mothers who are stressed show elevated levels of cortisol in spinal fluid as adults.Coplan et al, 1996Peer-reared vs. Mother-reared differ in neurotransmitter systems: not synchronized, not stable; blunted system (as in vets); behavior more aggressiveKraemer & Clark, 1996Conclusion: Infant open bio-behavioral system takes cues from the environment
30Human Studies of Attachment In Strange Situation Studies:Main & Morgan, 199680% of maltreated infants showed Disorganized (Type D) AttachmentSpangler & Grossman, 1999Inability to organize coherent strategy for eliciting comfort from caregiver is differentially associated with increased release of stress hormones and higher heart rates.
31Attachment and Psychopathology Research DissociationLongitudinal Studies (Minnesota and Harvard)Predictors of Adolescent Dissociation:Not Physical, Sexual Abuse or witnessing violenceAt 24 months of age: Psychological unavailability of caregiver and disorganized attachment (Ogawa et al, 1997);39% variance accounted for by Quality of early maternal care (Harvard Longitudinal Study)Conduct DisorderAttachment difficulties are correlated with early onset Conduct Disorder (Schore, 2005)
32Attachment and Psychopathology Research Borderline Personality DisorderPredictors of Borderline Personality Disorder (Minnesota and Harvard Longitudinal Studies)Early referral for caregiver problemsWithdrawal of motherGenetic Predisposition: Serotonin Transporter variantsLater abuse does add to modelBPD predicted by absence of mentalization and hx of abuse(Fonagy, 2005)
33Conclusions Lyons-Ruth and Hennighausen (2005) Disorganized attachment processes are early predictors of both internalizing and externalizing forms of psychopathology from the pre-school period onward.Attachment interacts with individual biological vulnerability to produce a range of psychiatric symptoms.
34Disorganized Attachment Patterns in Infancy Can Result in Chaotic/Negative Sense of SelfImpaired development of “Mentalization” (Fonagy)Capacity for affect regulation and a reflective functionIndividual cannot mediate heightened emotional experiences with left brain (goes Limbic)Experience emotions as “being” instead of “feeling”Higher levels of stress hormones (cortisol) built into systemDissociative mental processes: Traumatic memory stored in RB
35Type D becomes Controlling Attachment Behavior (ages 2-8) Care-giving ControlUndue attention to parentOrganize, direct, or entertain parentAggressor or Victim with peersInhibited playPunitive ControlEscalating non-complianceBehaviors punish, humiliate parentAggressive with Peers
36Adult Analogs of Type D Care-Giving Control becomes Helpless Subtype Unsuccessful attempts to master painPervasive fearMay ID with caregiver: Caregiver helpless/abdicating/unable to protectPunitive Control becomes Hostile SubtypeEmotionally closed downMake light of abuse/painGlobal devaluation of caregiverCan lack empathy with own childrenMany People mixed Helpless/Hostile
37Attachment Applications to College Student Clients Intense perfectionism that is resistant to tx may reflect Mixed Hostile/Helpless TypeFeels worthless, ashamed, vulnerable, self-criticalDemanding in relationshipsPeople pleasing, but critical when needs not metTalented, but inhibited in school and career
38Tx for Hostile/Helpless Type Identify Emotional/Behavioral Patterns as AdaptationCaregiving Pattern:Survival: what would have happened if didn’tProtect from further harm: being invisible, being “good girl/boy”Protect self from overwhelming feelingsIn service of getting “emotional oxygen”: recognition at times, praise, “crumbs”.Preserve relationship in familySelf-esteem
39Tx cont. Negative Voice Preserves hope of parental care Abuse/Neglect must be about meSemblance of ControlIs relational effortIs only a story, not truth about self
40Corrective Emotional Experience in Therapy Schore: Implicit Communication within the Therapeutic AllianceIn co-created “heightened affective moments” and episodes of interactive repair empathic therapist’s right brain can regulate patient’s right brain negative and positive affective states”Limbic system is elasticTherapy induces change in emotion processing regulatory structures.Limbic system allows brain to adapt and organize new learningRuptures in therapy mimic stressful situations for infantsAppropriate, empathic responding can change internal relational representations over time.Change is in the Repair: Perfect therapists don’t promote change
41RH and Transference/ Countertransference Shuren & Grafman (Arch.Neurology, 2002)“The right hemisphere hold representations (interjections, object relations, Bowlby’s IWM’s (Internal Working Models) of the emotional states associated with events experienced by the individual. When that individual encounters a familiar scenario, representations of past emotional experiences are retrieved by the RH and incorporated into the reasoning process.”Limbic System goes through RB to LB
42General Therapy Guidelines with Attachment Disordered Clients (BPD) Needs to be emotionally based to learn emotional regulationLimitations of verbal therapiesWork on developing “Mentalization”DBT works well because offers corrective emotional experience and skill-building in mindfulness, mentalization, etc.
43Therapy Cont. Amini et al (Psychiatry, 1996) Psychotherapy works because it is “an attachment relationship capable of regulating neurophysiology and altering underlying neural structure.”Judith Beck at APA: with Axis II clients CBT doesn’t work until relationship is established and emotional processing accomplished.
44ReferencesBowlby, J. (1988). A secure base: Parent-Child attachment and healthy human development. New York: Basic Books, Inc.Cashdon, S. (1988). Object relations therapy. New York: W.W. Norton & Company:Melnick, S. (2005). “Trauma and Attachment” Presentation at the Harvard Medical School Attachment and Related Disorders conference, Boston, May 7, 2005.Shore, A. (2003). Affect disregulation and disorders of the self. New York: Norton.Shore, A. (2005). “Recent Advances in the Neurobiology of Attachment: Implications for Interventions and Prevention.” Presentation at the Harvard Medical School Attachment and Related Disorders conference, Boston, May 6, 2005.