Transcript Attachment: A Look from the Inside Out

Allison Sampson, PhD, LCSW, LICSW, CSOTP
ATTACHMENT:
A LOOK FROM THE INSIDE OUT
Information and slide part of Dr. Allison Sampson's Trauma Presentation
I am a child …
http://scm-l3.technorati.com/11/02/07/26561/TypesOfChildAbuse.JPG
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Attachment … the next missing link
Attachment ….. The next link ….
 Not just a human behavior model
 Linked to trauma if our caregiving environment
was where the trauma occurred
 What did we learn from our caregiving
experiences ?
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Trauma Goals Attachment Class
Focuses On
 Self-Regulation
 relationship with self
 Positive Self-Identity
 Implicit memory about self, others and the world
 Co-Regulation
 Relationship with others
 Safe Relationships
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Attachment Theory
Review of Attachment Theory and its
contribution to understanding and working
with youth with conduct related behavior
problems will follow …
Information comes from Bowlby and Ainsworth
references unless otherwise indicated
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Attachment Theory
 Bowlby is generally considered the father
of attachment theory
 He defined attachment as a strong
affectional bond developed by humans
toward particular others
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Context of Attachment theory
 Tradition of psychoanalytic theory
 Mother-child tie was based on food
 Food and sex were primary drives for
all other behaviors
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Bowlby’s Challenge
 Bowlby asserts mother and child tie is not
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secondary
Bonding is an instinctual behavior
Exists in many species of animals
Exists in humans
Presents evidence
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Key points about Bowlby
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Instinctiveness of attachment behavior
Defining attachment behavior through proximity
Focus on normal attachment behaviors
Normalization of distress
Emotions as signals
Grief and loss and attachment behavior
Phases of grief
Development of Internal Working Models
Attachment patterns
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Humans: Labile Systems
 Adaptable to many types of environments
 Long infancy
 Protection from predators is needed to
survive
 Proximity with someone who can protect us
is essential for our survival
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Limits of Labile System’s
Flexibility
 There are limits to our adaptability
 We cannot thrive in certain environments
 Assertion: If we are not able to have
proximity with another figure, we will not
grow and thrive as we are designed
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Proximity and Survival
 Proximity is key to human survival
 Certain behavioral systems ensure proximity
 Attachment behaviors ensures this proximity
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Attachment Behavior and Caregiving
Figure
 Attachment behaviors direction
 Goal of behavior
 Activation and Termination
Figure provides:
 Secure base to explore the world
 Ensures survival and safety
 Usually is our primary caregiver
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Attach and Explore …
 ..\..\My Documents\CEU\ASWB
Application\Attachment DL Course\Material
for Attachment Class\Materials and Videos to
Show for Presentation\Attachment and
Exploratory Behaviors_0001.wmv
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Importance of Secure Base
 Figure is our secure base
 Need this base for survival
 Provides learning time (adaptation)
 Caregiver provides us what we need to grow
and adapt to our environment
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Emotions as Signals for Attachment
Behavior
 Signal disruption in our homeostasis (proximity)
 Intense emotions related to activation of
attachment behavior
 Absence, distance, or rebuffing from a
significant person in our life
 Exists throughout lifespan
 Instinctual emotional response to a disaster,
intense anxiety, or illness
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Normalization
 Proximity is normal and biological
 Intense emotions are normal when proximity
is threatened
 Separation is a threat that activates
attachment behaviors (trauma)
 Not pathologic
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Grief and Loss:
An expression of attachment
behavior
 Experience of separation from attachment figure
 Focus on typical experience of grief
 Laid out a pattern of grief and loss
 Concern when child cannot move through the
grieving process
 NOT when child experiences grief
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Healthy Response to Grief
 Urge to Recover Lost Figure
 Relinquishing Recovery Process
 Reorganizing
 Engaging in Attachment with Others
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Urge to Recover Lost Figure
 Will involve Anger
 Anger gives energy
 Allows for detachment and reorganization
 Aggression stems from proximity :
Keeping predators away from figure
Rebuffing figure for separation
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Internal Working Models
 Experiences lead to a model in our mind of
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self, others, and the world
Patterns of relationships
Shapes the way we view self, others, and the
world
Affects cognitive processes
Involved in information
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Homework
 What can we do in Session to catch a glimpse
of internal working models with families?
 Assignment One: Observation
 Assignment Two: Story Stem Practice
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Mary Ainsworth’s Focus
 Conducted research in Uganda and Baltimore
 Supported development of description of
attachment patterns
 Wanted future research to explore individual
differences
 See if these patterns continue in other stages
of the lifespan
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Understanding Attachment Style
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Types of Attachment” by R.J. Werner-Wilson, 2006, Iowa State University.
(Slide 17)
Child Attachment Style Adult Attachment Style
Secure: limited distress; continued
exploration after initial reunion
Secure/Autonomous: dev.-approp. interac.;
recognizes sig. of attachment
Avoidant: child appears indifferent
Dismissing: dismissive about attachment;
withdrawn and rejecting
Resistant or Ambivalent: child appears
distressed, preoccupied with caregiver &
“clingy”
Preoccupied: recognizes sig. Of
attachment, but preoccupied with past;
appears angry; blurred boundaries
Disorganized/
Disoriented: difficult to categorize reunion
experience (80% of maltreated youth)
Unresolved/
Disorganized: frightened by memory of
past trauma promotes momentary
dissassociation; scripts child into “past
drama”
Information and slide part of Dr. Allison
Sampson's Trauma Presentation
Attachment Assessment Tools
 Constructive Family Tasks (assessing verbal
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and non verbal behaviors)
Story Stems for younger children
IPPA (Inventory or Parent and Peer
Attachment)
AAI (Adult Attachment Interview)
AAP (Adult Attachment Projective Picture
System)
ECR-R (Emotional Closeness in Relationships
Scales)
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AAI Interpretation
Ronald Jay Werner-Wilson, Ph.D. (2006)
Department of Human Development and Family Studies
Iowa State University
 The responses are evaluated on two
dimensions.
 The first dimension is coherence. Coherence
refers to answers that
 provide a clear and convincing description;
 are truthful, succinct, and complete;
 are presented in a clear and orderly manner.
 The second dimension is the ability to reflect on
the motives of others.
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ECR-R Plotting Graph
Low Avoidance
Secure
Preoccupied
High Anxiety
Low Anxiety
Fearful/Avoidant
Dismissing
High Avoidance
Information and slide part of Dr. Allison
Sampson's Trauma Presentation
Additional Attachment
Perspective
Daniel Siegal, MD (1999)
 Looks at experience dependent mind
 Neuroplasticity (structure and function)
 Challenges nature/nurture dichotomy
 Interest in neuroscience, attachment, and
interpersonal relationship development
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Interpersonal Meaning
What this means is that interpersonal
experiences shape the firing patterns
and thus how the flow of energy and
information is conducted in the body
throughout the life span
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Mind Defined (Sigel, 2007)
 Mind – “a process that regulates the flow of
energy and information” (p.5)
 Energy and info within the body
 Energy and info within relationships between
people
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Experienced Based Brain
Adapted from Siegel, 1999
Structure
Neural Circuits
Mind
Integration
Individual
Experience
Brain
Function
Plasticity
Family
Community
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Attachment
Many argue that these early relationships
(experiences) shape neuronal circuits which
regulate emotional and social functioning
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Attachment’s Purpose
Siegel, 1999
Evolutionary Level – biological
Infant Survival (Bowlby)
Mind Level – biological and social
 Caregiver’s brain helps child’s brain to organize
regulation
 Caregiver’s brain teaches child self-soothing
 Child experience of safety allows for exploration
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Attachment’s Purpose
Experience of safety is encoded in child’s
implicit memory and provides secure base
from which to grow and access higher levels
of information processing
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Impact of Secure Attachment
Associated with …
 Emotional Regulation
 Social Relatedness
 Access to autobiographical memory
 Sense of self in time (presence)
 Development of Self-Reflection and Narrative
Main (1995), Main et. al. (1985), Fox et. Al. (1994), Oppenheim and Waters (1995)
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Wellness
 Ability to have balance between biological
demands and social demands (self regulation)
 Ability to be present in the moment
 Ability to separate past from present
 I am NOT what happened to me (self-identity)
 Ability to be attune to others (co-regulation)
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Important Themes for Clinical Work
How individuals relate to self, others, and world
impacted by:
 How they were taught and experienced
relationships
 Perceptions of these experiences
 Biologically, impact of these experiences could
alter the way they engage/interpret new
experiences …
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Clinical Significance
Focus treatment towards:
 SAFETY and RELAXATION for both caregiver and
child
 Creating new opportunities for positive
experiences within a caregiving relationship
 New experiences of becoming present in the
moment and aware of energy
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Memory and Attachment
How relationships with our self, others, and the
world are stored in our body
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Memory
 Is not a static process
 Involves
 Constructing of new neural network profiles
 Constructed with features of old engram
 Elements from other experiences
 Present state of mind
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Memory
Engram: Initial impact of an experience
 Semantic: Factual information
 Autobiographical: Sense of self in time
 Somatic: Sense of body at time
 Perception: Senses
 Behavioral: What we do
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Memory
Explicit Memory
 Semantic: Factual information
 Autobiographical: Sense of self in time
Implicit Memory
 Somatic: Sense of body at time
 Perception: Senses
 Behavioral: What we did with our body
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Implicit Memory
 Involves parts of the brain that do not require
conscious processing
 Infants have access to this memory
 “Mental Models” are created from these
repeated experiences
 “Mental Models” allow for assessing
situations rapidly and determine what may
happen next
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Explicit Memory
 Involves conscious awareness of encoding and
recollection
 Includes semantic and autobiographical memory
 Requires focal attention
 Cortical consolidation makes selected events part of
permanent memory
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Experiential Exercise …
(Stress cards and stickers)
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Looking through their eyes …
Explicit memory and understanding easier for
clinicians
Implicit emotional understanding is more
difficult … pay attention to your implicit
experience to the music and pictures …
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A secure base …..
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
Thoughts …
 What feelings arise?
 Were you aware of memories you
connected to …
 Body sensations …
 Anticipation of what would come
next …
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A child’s eyes ….
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
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Sampson's Trauma Presentation
What is the picture now …
 What feelings arise now ?
 Were you aware of memories you
connected to …
 Body sensations …
 Anticipation of what would come next …
 What do these pictures give you in terms
of sense of self, others, and the world …
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Implicit versus Explicit
 What is the experience of the implicit
memory versus the explicit understanding?
 Is one more powerful than the other?
 Would having mixed the two sets of pictures
lessened or intensified the experience?
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Stress, Trauma, and Memory
Therefore, “unresolved” trauma has
important implications for:
 Mind Functioning (Our Experiences)
 Interpersonal Relationships
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Implications
Implicit mental models shape the
organization of explicit autobiographical
memory. When the implicit models become
unstable it in turn intrudes on the way we
relate to our self, others, and the world … the
way we experience life
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Implications
Our autobiographical memory is what allows us to sequence
our life and organize our sense of self and others across time
Damage to our ability to access autobiographical memory
results in the loss of our self in our own story
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Importance of the Story
Stories are:
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The way we organize the world through sequencing
Connect our experience with others
Share our cultural rules and expectations
Learn perspectives of the teller and listener
Resolve conflict
Engage and create our social experience
Establish our sense of self
Captivate us and engage us in active co-construction
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Importance of Stories
Without our stories … we only exist as a set of
behaviors that happen in different moments
with no concept of self, time, connection or
sequence
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Children and Adults who have experienced trauma
have disruptions in their attachment …
What are the take aways?
 Insecure bonds with their caregivers
 Often leads insecure attachment
 Difficulty in creating close relationships
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Developmental Trauma Disorder
Van der Kolk
http://www.cathymalchiodi.com/dtd_nctsn.pdf
Argument that this children’s trauma occurs
within the context of a relationship while their
brain is still developing … looks different from
an adult with PTSD
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Assessment … Where to begin?
 TIC ASSESSMENT.pdf
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Interventions … what’s out there ?
 TIC INTERVENTIONS.pdf
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Three Targets Goals in
Treatment
 Self-Regulation
 Positive Self-Identity
 Co-Regulation
 Secure Relationship
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Phase Oriented Treatment
van der Kolk, et al. (1996)
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Stabilization
De-conditioning of traumatic memories
Restructuring of traumatic personal schemes
Reestablishing of secure social connections
Accumulation of restitutive emotional
experiences
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Maslow’s Hierarchy of Needs
(adapted by McCreeden, 2004)
Self Actualization
Artistic Needs
Cognitive Needs
Self Esteem
Belonging
Safety Needs
Physical Needs
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Core areas of focus in Complex
Trauma
Courtois, C. & Ford, J. (2009), Introduction (p.2)
 Self-Regulation
 Affect Regulation
 Disassociation (difficulty in being “present”)
 Somatic Dysregulation
 Self-Identity
 Impaired Self-Concept
 Impaired Self-Development
 Co-regulation
 Secure working model of caring relationship
 Disorganized Attachment Patterns
Phase Oriented Treatment
“Gold Standard”
Phase I: Safety and Stabilization
Phase 2: Trauma Reprocessing
Phase 3: Reintegration
Courtois, C., Ford, J., & M. Cloitre (2009), pp.90-100
Phase Oriented Treatment
Courtois, C., Ford, J., & M. Cloitre (2009), pp.90100
PHASE ONE: Safety and Stabilization
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Personal and Interpersonal Safety Established: Education/Support/Safety Planning
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Enhance Client’s ability to manage extreme arousal (hyper/hypo)
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Active engagement in positive/negative experiences (deal with automatic avoidance behaviors, self awareness
of avoidance, increase coping skills and use of coping skills)
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Education (psychotherapy, trauma, skills to be learned)
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Assess and develop relationship capacity (decrease avoidance of relationships or negative thoughts about
relationships, build support network, define client’s attachment network)
PHASE TWO: Trauma Reprocessing
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Disclosure of traumatic memories, development of an autobiographical narrative (identify emotions connected
to trauma memories, grieve and mourn losses, resolution of relationships when appropriate, increased
awareness, increase interpersonal and self-regulation skills)
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Supporting client in maintaining functioning and not getting lost in memories or seeing themselves as
“disabled”, need to affirm strengths, promote positive self-esteem, and internal and external resources now
available to them
PHASE THREE: Re-Integration
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Growth and period and reengagement in life
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Can be time of client realizing losses, discover of unresolved developmental deficits, fine tuning of selfregulation skills
Contextual Models of Care
Gold, S. (2009) pp.231-235
 Interpersonal Area
 Collaborative approach
 Attachment in the therapeutic relationship
 Practical Area
 Skill Development
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Self-Soothe
Being in the Present
Cognitive Strategies (problem solving)
Release of addiction/maladaptive behaviors
Traumatic Stress Reprocessing
Engaging in Daily Life
 Conceptual Area
 Clinician is a guide through the process
 Client develops the conclusions and outcomes
TF-CBT Components of Treatment
(Murray, Mannarino, Cohen, Deblinger, 2008 PP Presentation)
 Psycho education
 Relaxation
 Affect Modulation
 Cognitive Processing
 Trauma Narrative
 In Vivo Desentization
 Conjoint Parent-Child Session
 Enhance Safety and Social Skills
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Allison’s Model of Care
AIM Forward Model of Care
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