1. Adapted by Ellaine B. Miller, Ph.D. From presentation by Margaret Keiley, Ed.D, LMFT Auburn University, AL 1

2. Challenging Provider Issues Make me Feel Like??? 2

3. 3

4. Attachment Theory Affect Theory Change Theory 4

5. Attachment Theory What is Attachment? Why does attachment exist? Survival mechanism To maintain the proximity with a caregiver, especially in a stressful situation Goal is to reduce arousal and reinstate a sense of felt security To provide a “secure base” from which to explore What about attachment and caregivers? 5

6. Attachment Styles Secure Warm, available, and responsive caregiver Ambivalent-insecure Inconsistent caregiver Avoidant-insecure Emotionally unavailable or rejecting caregiver Disorganized Intrusive, abusive caregiver Insecure attachment styles interfere with a person’s ability to regulate affect and to explore his/her world 6

7. Internal Working Models Working models of the world Who attachment figures are and how one might expect them to respond Working models of the self How acceptable or unacceptable one is in the eyes of attachment figures These internal working models of how attachment relationships operate predispose individuals to habitual forms of engagement with others, including the regulation of affect 7

8. Internal Working Models (Cont.) Secure: Self is worthy and competent; world and others seen as safe and trustworthy Anxious: Self is unworthy; world and others seen as undependable and rejecting Avoidant: Self is unlovable, incompetent, never good enough; the world and others are seen as untrustworthy and never satisfied Disorganized: No organized internal working models Last three attachment IWMs are driven by FEAR of: Rejection, Incompetence, Caregiver 8

9. Affect Theory What is affect? Information about our experience and desire How is affect regulated? Affect regulation involves tolerance, awareness, expression, and control of the physiological, behavioral, and experiential aspects of affect Affect regulation is first co-constructed as part of the attachment process in infancy 9 We need access to the information that is contained in affect in order to make decisions about what we want & how we want get what we want. So it must be regulated.

10. Link between Affect & Attachment Secure individuals are able to flexibly manage their emotions and their distance from others in conflictual interactions Ambivalently (Anxiously) attached individuals tend to heighten distress and anger as well as pursue in conflictural interactions Avoidantly attached individuals tend to restrict the communication of anger and distress and withdraw from conflictual interactions Disorganized individuals have no organized attachment strategies or affect regulation strategies: Sometimes pursue and heighten distress, sometimes withdraw and restrict expression 10

11. Examples of the Links between Affect & Attachment Secure Overtly/Hidden: express vulnerable feelings Ambivalent Overtly: nagging, angry criticism, and pursuit Hidden: fear of rejection or sadness about disconnection Avoidant Overtly: stonewalling, withdrawing, or flat affect Hidden: anger, hurt, sadness, and fear of incompetence Disorganized Overtly: stonewalling, withdrawing, flat affect, pursuit, anger Hidden: terror, terror, terror 11

12. Summary MAP: Attachment Positions and Affects Secure: Flexibility in movement toward and away from the other and tolerance of own and others’ affect (not afraid of feelings) Ambivalent: Pursue, show distress, hide sadness and fear Avoidant: Withdraw, show little distress, hide anger, fear, and sadness Disorganized: No organized position, vulnerability always hidden, terrified 12

13. Physiology of Affect The regulation of emotional arousal is the key factor in determining the nature and form of close relationships. (Porges’ Polyvagal Theory and Gray’s Motivational Theory) Emotional arousal gets our attention. THEN We are able to calm ourselves, attend to what is in front of us and respond appropriately. We can regulate the arousal in order to keep it in the tolerable zone (SECURE) Or we move into a highly aroused panic mode that is not cognitively controlled. The result is we revert to a habitual mode of interaction, either fighting (rage, AMBIVALENT/ANXIOUS) or fleeing (fear, AVOIDANT) 13

14. High Arousal (Red Zone) When you are highly aroused and in a panic mode, you CANNOT engage your brain to make decisions You go directly into a habitual mode of response without thinking: Flight, Fight, or Freeze 14

15. Central Nervous System Autonomic Nervous System Sympathetic Nervous System Motivational Functioning Parasympathetic Nervous System Regulatory Functioning Reward System: Behavioral Activation System (BAS) (Dopamine System) Punishment System: Behavioral Inhibition System (BIS) (Serotonin System) Vagal Complex: Vagus Nerve, Dorsal Motor Nucleus, Nucleus Ambiguous Vagal Tone: Emotional Trait Vagal Reactivity or Vagal “Brake”: Emotional State 15

16. Vagal Tone (VT): Heart Rate Variability High VT: Heart rate variability high: Easier to regulate reactivity appropriately; emotional & communication flexibility Associated with better child, adult outcomes Low VT: Heart rate variability low: Harder to regulate reactivity appropriately; emotional inflexibility and communication difficulties Associated with both externalizing and internalizing problems Aggression – anger, rage Depression – sadness Anxiety – fear, panic 16

17. Vagal Reactivity (VR): RSA Reactivity This vagal “brake” regulates heart rate increases and decreases to deal with environmental demands VR facilitates effective coping with challenges by allocating cognitive and motivational resources VR reflects intra-individual shifts in levels of fear and anger Moderate VR: Optimal engagement, prepare to respond Excessive VR: Emotional lability Vagal tone stabilizes by age 1, but vagal reactivity is somewhat amenable to alteration and change 17

18. Porges’ Polyvagal Theory (PNS): Regulatory Functioning Influences on the Heart: Vegetative Vagus – Deceleration of heart rate associated with orienting (older, reptilian brain) Smart Vagus – After orienting Decision Point: One of two decisions (mammalian brain) 1. Attend to and engage: Sustained attention and further deceleration of heart rate 2. Fight-Flight: Rage-Panic: Excessive acceleration of heart rate and enlist SNS 18

19. 19

20. Change is Hard Why? What can we do about it? 20

21. Stages of Change Precontemplation Contemplation Preparation/Determination Action/Willpower Maintenance Relapse 21

22. 1 st order : De-escalation 2 nd order : Permanent Change 22

23. Mechanism of Change Low Arousal (First Order Change) Cognitive change – Reframe allows for awareness of initial internal working models (Emotional and Cognitive changes) Behavioral changes – De-escalation of cycles High Arousal (Second Order Change) Repeated in-session Change of Cycles Consolidation of change of relationship cycles (out- of-session change) 23

24. Low Arousal: 1 st Order Change De-Escalation of Cycles with Reframe The trainer reframes providers’ overt feelings and behaviors to illuminate their vulnerable feelings, attachment desires and positions, and the consequences of their behaviors The results of reframing are: Cognitive change Internal working models change (Emotional and Cognitive changes) Behavioral changes – De-escalation of cycles 24

25. High Arousal: 2 nd Order Change 25 Training Visit Interventions and Directives The trainer directs the provider to respond in a different way. To express his/her vulnerable feelings to the other, that is to ask directly for what she or he wants Or to help him/her to hear, understand, and respond to this expression of vulnerable feelings and attachment needs This directive RAISES the AROUSAL LEVEL of the participants Over time, the participants learn to take new positions with each other and that helps to reorganize their interactional patterns

26. Evoking High Arousal Only evoke the vulnerable feelings of the provider Fear Sadness Incompetence/Anger of the withdrawer Do not evoke the overt or defensive feelings Rage, Anger Shame Embarrassment 26

27. Q&A Do we think we know what our own attachment style is? Do we have an idea of what our providers’ attachment styles are? Having and idea about our own and others’ styles can help us engage with others in a more positive and productive way. 27

29. Types of Providers What are the characteristics of the providers you are involved with? Can we create profiles?

30. Styles of Engagement How do we relate to or engage in meaningful conversation with each type? Is this a one-size fits all approach? Do we need different approaches?

31. 31 1. Engagement 2. Assessment 3. 1 st Order Change: Reframe 4. 2 nd Order Change: Directives 5. Consolidation

32. Engagement Strategies 32 Empathy Validation & Normalization Heightening Vulnerable Feelings The Use of Metaphors & Stories

33. Assessment What is assessed? Attachment positions Overt and vulnerable feelings related to positions Interactional cycles and consequences We assess these things by tracking and reflecting the interactional cycles and the consequences 33

34. 1 st Order Change -- REFRAME Address negative feelings (yours and provider’s) Change the script Stop the cycle 34

35. 2 nd order change -- DIRECTIVES Change the cycle Stop Think Respond differently Practice, practice, practice Needs to hold up under stress 35

36. Practicing Strategies Applying the theories Role play 36

37. Summary Attachment style Affect/vagal tone Change is hard Culture Family of origin Present situations History Trust 37