Transcript Document 7113002

Developing a Secure Base:
Application of Attachment Theory to
Clinical Practice
Douglas Goldsmith, Ph.D.
Executive Director
The Children’s Center
Overview
Foundations of Clinical Practice
 Attachment theory

– Strange Situation
Internal Working Models
 Reflective Functioning
 Maternal Representations

– Adult Attachment Interview
Insightfulness
 Treatment implications

Clinical Practice

Referral
Intake
Assessment
Treatment
Discharge
Good Progress!
Poor Progress
Child
Parents
System
Med Management
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

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

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

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)
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

Attachment Classifications

The strange situation
– Secure
65%
– Avoidant
20%
– Ambivalent
10%
– Disorganized 5-10% (80% maltreated)
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
Secure Attachment

Child feels safe and secure
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
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
Insecure Attachment
Intense love and dependency
 Fear of rejection
 Irritability
 Vigilance
 Punish their attachment figure for any
sign of abandonment

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)
Disorganized (D)
Behavior lacks an observable goal
 Look fearful
 Behavior is bizarre
 May try to leave after the reunion or
freeze

Attachment Relationship
Proximity Seeking
 Secure base effect
 Separation protest

Attachment Behavioral System
Attachment figure:
Near, responsive,
attuned
Felt security, love,
self-confidence
Playful, smiling,
Exploratory, sociable
Holmes (1993)
Attachment Behavioral System
Attachment
Figure:
Distant,
Unresponsive
Poor attunement
Visual checking
Pleading
Clinging
Holmes (1993)
Fear
Anxiety
Defensive
Avoidant
Watchful
Wary
Ambivalent
Clinging
Angry
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

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

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
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

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
Securely Attached Child

Internal Working Model
– Responsive, loving, reliable caregiver
– Self is worthy of love and attention
Holmes (1993)
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
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.
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
Mothers of Secure Infants
Continuously monitor the infant’s state
 Accurately interpret the signal for
attention
 Act accordingly to meet the infant’s
needs

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

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)
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)
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)
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
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)
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)
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)
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)
Adult Attachment Interview

Secure-Autonomous
– Coherent
– Not overwhelmed by emotion
– Show compassion, humor, forgiveness,
awareness of unconscious, awareness of
lack of perfection
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
AAI

Dismissing
– Push aside experiences
– May idealize parents
– Avoid emotional aspects
– “Nothing negative in my childhood”
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
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
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 selfknowledge
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
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
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)
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)
Maternal Attributions:
Protective Function
Child feels adored
 Allow child to cope with self-doubts and
feelings of despair
 Allow parent to better tolerate selfsacrifices that are integral to the
parenting process
Lieberman (2000)

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)
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)
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)

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)
Disengaged
Lack emotional involvement
 Minimally attempt to understand what’s
on their child’s mind
Oppenheim (1999)

Video
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.
Ports of Entry
Developmental Information
 Parent-child relationship
 Projections onto the child
Lieberman (1999)

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)
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
Secure Attachment Formula
 Always
be bigger, wiser, and kind
 Whenever possible, follow the
child’s lead
 Whenever necessary, take charge
Marvin, et al (2002)
Cooper, Hoffman, Marvin &Powell , 2000
Cooper, Hoffman, Marvin &Powell , 2000
Cooper, Hoffman, Marvin &Powell , 2000
Cooper, Hoffman, Marvin &Powell , 2000
Cooper, Hoffman, Marvin &Powell, 2000
Negative Maternal Attributions

Determine whether and how mother will
respond to, misinterpret, or ignore
certain behaviors
Lieberman (2000)
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

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?

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)
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

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.”
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

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”.

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)
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.
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!
Safe Haven
Comfort level with nurturing
 Emotional/Physical availability
 Negative projections

Treatment Approaches
Bridging affect
 Present the child’s point of view
 “Challenge” the parent’s interpretation
of the child’s behavior

Secure Base Interventions
Nurturing
 Anticipating needs
 Helping child regulate emotions
 Parental emotional availability
 Structure and consistency
 Experience of being in one’s mind

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

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)