1. Developing a Secure Base: Application of Attachment Theory to Clinical Practice Douglas Goldsmith, Ph.D. Executive Director The Children ’ s Center

2. Overview Foundations of Clinical Practice Attachment theory –Strange Situation Internal Working Models Reflective Functioning Maternal Representations –Adult Attachment Interview Insightfulness Treatment implications

3. Clinical Practice Referral Intake Assessment Treatment Discharge

4. Good Progress!

5. Poor Progress Child Parents System Med Management

6. Alternative Hypotheses Inadequate assessment Failure to accurately diagnose the child Failure to accurately assess family dynamics Failure to formulate the case Failure to address the relationship issues

7. Added value of attachment theory and developmental concepts: Provides foundation for conceptualization of the parent-child relationship Able to focus interventions on repair of relationship-based issues even when a diagnosable condition exists

8. Attachment Emotional bond with another person Behaviors promote proximity with one perceived as older, stronger, and wiser Motivational system to seek proximity Enhances feelings of security Motivates baby to take action when frightened

9. Attachment Theory When I am close to my loved one I feel good, when I am far away I am anxious, sad or lonely Attachment is mediated by looking, hearing, and holding When I ’ m held I feel warm, safe, and comforted Results in a relaxed state so that one can, again, begin to explore Holmes (1993)

10. Attachment in Action Behaviors shown by careseeker and caregiver Aware of and seek each other out if careseeker is in danger due to physical separation, illness, or fright

11. Attachment Classifications The strange situation –Secure 65% –Avoidant 20% –Ambivalent 10% –Disorganized 5-10% (80% maltreated)

12. Secure (B) Uses mother as secure base Signs of missing mother Actively greets with smile or gesture Signals or seeks contact if upset Once comforted resumes exploration Solomon & George (1999) p.291

13. Secure Attachment Child feels safe and secure

14. Avoidant (A) Explores readily Little visible distress when left alone Upon reunion, looks away or actively avoids May stiffen or lean away if picked up Solomon & George (1999) p. 291

15. Ambivalent (C) Distressed, fretful, passive Fails to explore Unsettled, distressed by separation Alternates bids for contact with signs of angry rejection Fails to find comfort from the parent Solomon & George (1999) p.291

16. Insecure Attachment Intense love and dependency Fear of rejection Irritability Vigilance Punish their attachment figure for any sign of abandonment

17. Insecure Attachment The insecurely attached person is saying: “ Cling as hard as you can to people – they are likely to abandon you: hang on to them and hurt them if they show signs of going away, then they may be less likely to do so. ” Holmes (1993)

18. Disorganized (D) Behavior lacks an observable goal Look fearful Behavior is bizarre May try to leave after the reunion or freeze

19. Attachment Relationship Proximity Seeking Secure base effect Separation protest

20. Attachment Behavioral System Attachment figure: Near, responsive, attuned Felt security, love, self-confidence Playful, smiling, Exploratory, sociable Holmes (1993)

21. Attachment Behavioral System Attachment Figure: Distant, Unresponsive Poor attunement Fear Anxiety Defensive Avoidant Watchful Wary Ambivalent Clinging Angry Holmes (1993) Visual checking Pleading Clinging

22. Attachment Problems Bowlby A severely hurt child fails to seek comfort Signals that ordinarily activate attachment behavior fail to do so System controlling attachment, and the feelings and desires associated, is rendered incapable of being aroused

23. Classification vs. Disorder Secure infants are at a decreased risk for psychopathology but not immune There is no clear link between insecure infants and psychopathology

24. Links to Other Disorders An avoidant child may develop a hostile, aggressive, antisocial pattern in response to experience with a rejecting and emotionally unavailable caregiver An ambivalent child may be easily overstimulated, showing impulsivity, restlessness, short attention span, and low frustration tolerance (Greenberg, 1999 p.481) Video

25. Internal Working Model Based on the child ’ s real-life experience of day to day interactions with his parents Reflects the images the parents have of the child Images communicated by how each parent treats the child and what each parent says to the child

26. Impact of the Internal Working Model The model governs how children feel toward each parent and about themselves, how they expect to be treated and how they plan their own behavior toward their parent

27. Securely Attached Child Internal Working Model –Responsive, loving, reliable caregiver –Self is worthy of love and attention Holmes (1993)

28. Insecurely Attached Child The world is dangerous Treat others with great caution Self is ineffective and unworthy of love These assumptions are stable and enduring and terribly difficult to modify Holmes (1993) Video

29. Development of Relationships “ For a relationship between any two individuals to proceed harmoniously each must be aware of the other ’ s point-of-view, his goals, feelings, and intentions, and each must so adjust his own behavior that some alignment of goals is negotiated.

30. Development of Relationships This requires that each should have reasonably accurate models of self and other which are regularly updated by free communication between them. It is here that the mothers of securely attached children excel, and those of the insecure are markedly deficient. ” Bowlby (1988) p. 131

31. Mothers of Secure Infants Continuously monitor the infant ’ s state Accurately interpret the signal for attention Act accordingly to meet the infant ’ s needs

32. Mother’s of Anxious Infants Monitor the infant ’ s state only sporadically Inconsistently notice the infant ’ s signals May interpret the signal inappropriately Respond to the signal inappropriately, or tardily

33. Impact of Anxious Attachment “ By the age of 12 months, there are children who no longer express to their mothers one of their deepest emotions or the equally deep-seated desire for comfort and reassurance. ” Bowlby (1988)

34. Ambivalently Attached Child Shows overt aggression toward the inconsistent mother “ Don ’ t you dare do that again! ” but has to cling because he knows from experience that she will. Holmes (1993)

35. Avoidant Child Outbursts of unprovoked aggression Needs to appease to the mother because the child wants so badly to feel close Fears she ’ ll rebuff him if needs are revealed too openly; or if anger about abandonment is shown too openly Holmes (1993)

36. Impact of Empathic Failure “ Whatever she fails to recognize in him he is likely to fail to recognize in himself. In this way, it is postulated, major parts of a child ’ s developing personality can become split off from, that is, out of communication with, those parts of his personality that his mother recognizes and responds to, which in some cases include features of personality that she is attributing to him wrongly. ” Bowlby (1988) p.132

37. Reflective Function “ The reflective function refers to the psychological processes underlying the capacity to mentalize... mentalizing refers to the capacity to perceive and understand oneself and others ’ behavior in terms of mental states, i.e., reflection. ” Fonagy, Steele, Steele & Target (1997)

38. Reflective Function Allows the individual to make sense of his or her own and others ’ psychological experience, to enter into another ’ s experience, to “ read ” another ’ s mind Allows the child to make others ’ behavior meaningful and predictable, and permits him to respond adaptively Slade (1999)

39. Reflective Function The mother ’ s capacity to understand the child ’ s mental states create the context for a secure attachment relationship The mother is able to view the infant as intentional Reflective functioning provides protection against damaging effects of abuse and trauma Slade (1999)

40. Reflective Function The capacity to tell a story that is affectively believable The capacity to understand emotional processes The ability to accurately understand ones own and others behavior Slade (2002)

41. Adult Attachment Interview Secure-Autonomous –Coherent –Not overwhelmed by emotion –Show compassion, humor, forgiveness, awareness of unconscious, awareness of lack of perfection

42. AAI Preoccupied –No overview –Ramble, get lost in memories –Talk about irrelevant issues –“ We did this, that, and the other thing ” –Seems angry, passive, or fearful

43. AAI Dismissing –Push aside experiences –May idealize parents –Avoid emotional aspects –“ Nothing negative in my childhood ”

44. AAI Unresolved –Lapses in monitoring –Indicate belief that a dead person is still alive or the person was killed by a childhood thought –Long silences

45. Dyadic Patterns Marvin et al (2002) Secure child – Autonomous Parent –Easily approach and interact when distressed –The reunion calms the child and facilitates exploration –Child can shift between exploration and using the parent as a safe harbor with little anxiety –Close attunement – disruptions easily repaired

46. Dyadic Patterns Marvin et al (2002) Insecure child – Dismissing Parent –Both partners minimize intimate attachment-caregiving interactions –Miscue – I ’ m really more interested in playing –“ Independence ” is highly valued –Overregulated affect, little emotional self- knowledge

47. Dyadic Patterns Marvin et al (2002) Insecure Child – Ambivalent/Preoccupied Parent –Both partners minimize independent exploration –Child is overly dependent on the parent –Miscue – don ’ t explore, there really is something to be anxious about –Under-regulated affect

48. Dyadic Patterns Marvin et al (2002) Insecure, Disordered Child Disorganized/ Insecure Parent –Parent fears or becomes angry in response to child ’ s attachment behavior and abdicates caregiving –Caregiver has unresolved trauma –Role reversed relationship

49. Maternal Attributions Fixed beliefs that the mother has about the child – “ beliefs that she perceives as objective, accurate perceptions of the child ’ s essence. ” Lieberman (2000)

50. Positive Maternal Attributions “ When a mother sees her child as the cutest, most intelligent, most endearing being ever created, she is summoning from the depths of herself the capacity for ecstasy that allows her to put up with the inevitably annoying, exasperating, or simply tedious aspects of raising a child. ” Lieberman (2000)

51. Maternal Attributions: Protective Function Child feels adored Allow child to cope with self-doubts and feelings of despair Allow parent to better tolerate self- sacrifices that are integral to the parenting process Lieberman (2000)

52. Affect Regulation We must develop in the mother flexible, affectively balanced and coherent representations of the child and the self as a parent. Slade (2002)

53. Parental Insightfulness “ Parental empathic understanding involves the capacity to see things from the child ’ s point of view within a balanced, accepting, and coherent frame. ” Oppenheim (2000)

54. Balanced Able to see experiences through their child ’ s eyes and make attempts to understand the underlying motives Talk openly about positive and negative aspects Oppenheim (1999)

55. One-sided Preset conception of their child Difficulty staying focused on their child and their relationship with the child Talk about their own feelings/issues Oppenheim (1999)

56. Disengaged Lack emotional involvement Minimally attempt to understand what ’ s on their child ’ s mind Oppenheim (1999) Video

57. Goal of Treatment Therapy must help the parents place the child ’ s behavior in the appropriate context in order to facilitate a response to the behavior that will nurture trust and security.

58. Ports of Entry Developmental Information Parent-child relationship Projections onto the child Lieberman (1999)

59. Treatment Considerations Secure-Autonomous –Cooperative with treatment –Appreciate attachment issues Dismissing –Dismiss importance of attachment issues –Uncomfortable, resistant, hostile Preoccupied –Want help but struggle to focus on task –Enmeshed in their own issues Dozier (2003)

60. Circle of Security Marvin, Cooper, Hoffman & Powell (2002) Child ’ s Exploratory System and Needs –The child can move off and explore, if he believes and expects that the attachment figure will be available if, or when, needed Attachment System –The child needs the attachment figure to be available to protect, comfort, delight, and organize his feelings when he becomes overwhelmed

61. Secure Attachment Formula Always be bigger, wiser, and kind Whenever possible, follow the child ’ s lead Whenever necessary, take charge Marvin, et al (2002)

62. Cooper, Hoffman, Marvin &Powell, 2000

67. Negative Maternal Attributions Determine whether and how mother will respond to, misinterpret, or ignore certain behaviors Lieberman (2000)

68. Observation of Parent-Child Relationship Observe proximity seeking behaviors Observe parental sensitivity and insightfulness Who does child seek out when frustrated or frightened Use doll play to assess attachment hierarchy

69. Assessment – Secure Base Over the past two weeks can you think of a time when your child was: –Hurt? –Frightened? –Separated from you? What did your child do? How did you respond?

70. Assessment of Parent’s Point of View Interview questions: –Could you give me a thumbnail sketch of your child? –Tell me about a time in the past two weeks when you and your child really clicked. –Tell me about a time when you didn ’ t. –What gives you the most joy in your relationship? –What gives you the most pain? –Where do you turn for emotional support? Steele (2003)

71. Treatment Considerations Example of Typical Process Parent complains about the child ’ s destructive behavior The therapist understands how upsetting the behavior must be to the parents The therapist responds by discussing ways to control the destructive behavior

72. Empathic Therapeutic Failures It is critical for the clinician to avoid making the faulty assumption that it is obvious why the referral behavior was so offensive to the parent. We must, instead, “ get into the parent ’ s head. ”

73. Treatment Considerations Avoiding Empathic Failures Avoid being an “ expert ” Be careful not to intellectualize Avoid being in a hurry to solve the problem The goal of the process is to thoughtfully explore with the parent the impact of the child ’ s behavior

74. Thoughtful Exploration Don ’ t jump to your own conclusion, let the parent ’ s responses guide you. Wonder aloud why the behavior of this child is so distressing for this parent. Listen for emotionally laden words, e.g. “ Control ”, “ manipulate ”.

75. Parental Empathic Understanding “ Parental empathic understanding involves the capacity to see things from the child ’ s point of view within a balanced, accepting, and coherent frame. ” Oppenheim (2000)

76. Goal of Treatment Therapy must help the parents place the child ’ s behavior in the appropriate context in order to facilitate a response to the behavior that will nurture trust and security.

77. Circle of Security Understanding Secure Base –Did/Does parent have a secure base? Negative Projections –He doesn ’ t care if I ’ m there for him –He doesn ’ t need me –She gets so frantic it ’ s like she ’ s crazy!

78. Safe Haven Comfort level with nurturing Emotional/Physical availability Negative projections

79. Treatment Approaches Bridging affect Present the child ’ s point of view “ Challenge ” the parent ’ s interpretation of the child ’ s behavior

80. Secure Base Interventions Nurturing Anticipating needs Helping child regulate emotions Parental emotional availability Structure and consistency Experience of being in one ’ s mind

81. Time In Stay close by to help the child calm down Avoid processing until the child is calm If child becomes aggressive distance yourself while reassuring the child that you ’ ll be available once the child is calm

82. Secure Base “ When a child is held in mind, the child feels it, and knows it. There is a sense of safety, of containment, and, most important, existence in that other, which has always seemed to me vital... It seems to me that one of life ’ s greatest privileges is just that – the experience of being held in someone ’ s mind. ” Pawl (1995)