Transcript Secure Attachment

ATTACHMENT
RELATED TRAUMA
AND EMDR
Patterns of Insecure
Attachment
Sandi Richman
ATTACHMENT
ATTACHMENT CLASSIFICATION

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Adult attachment classification can be an
important aspect of case formulation
Attachment literature suggests in the context
of the AIP model that patterns of attachment
shaped in early caregiver experiences
influence all later adaptive and maladaptive
coping responses
Daniel Siegel (2010) : The best predictor of a
child’s security of attachment is how his/her
parents made sense of their own childhood
experiences
LIFE STORIES
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By asking certain kinds of autobiographical
questions, we can discover how people have
made sense of their past
Each individual’s life story is defined by :
 The way we feel about the past
 Our understanding of why people behaved as
they did
 The impact of those events on our development
into adulthood
This internal narrative may be limiting an individual
in the present.
LIFE STORIES

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Parents who had a rough childhood and
were unable to make sense of what
happened would be likely to pass on that
harshness to their own children who would in
turn pass on this legacy to the next
generation
Parents who had a tough time in childhood
but did make sense of those experiences
were found to have children who were
securely attached to them : they had
stopped handing down the family legacy of
insecure attachment
LIFE STORIES
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When taking a history, how an adult tells his or
her story can be revealing
Securely attached people acknowledge
both positive and negative aspects of family
experiences
Securely attached people can give a
coherent account of their past and how they
came to be who they are as adults
In contrast, people who had challenging
childhood experiences often have a life
narrative that is incoherent
LIFE STORIES
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We can change our lives by developing a
“coherent” narrative even if we did not start out with
one
Through EMDR treatment, and the AIP model, our
clients who had difficult experiences early in life find
a way to make sense of how those experiences have
affected them and their current responses
Through analysis of questioning in the Adult
Attachment Interview, the AAI questions reveal an
‘adult state of mind’ with respect to attachment
A child’s attachment behaviour in childhood
predicted the type of narrative developed as an
adult
CORRESPONDENCE OF ADULT
AND CHILD ATTACHMENT
ADULT NARRATIVE
INFANT STRANGE
SITUATION BEHAVIOUR
 Secure
 Secure
 Dismissing
 Avoidant
 Preoccupied
 Ambivalent
 Unresolved/Dis-
 Disorganised/Dis-
organised
oriented
SECURE NARRATIVE
My Dad struggled to get a job and support us.
He was irritable and often shouted at us. I
didn’t feel close to him but my Mom helped me
to understand how painful his situation was for
us all. As I got older I felt sympathy for him, got
over my anger and had a much closer
relationship with him. It is easy for me to
become emotionally close to others. I am
comfortable depending on others and having
others depend on me. I don’t worry about
being alone or having others not accept me.
DISMISSING NARRATIVE
My childhood was fine. My Dad was an accountant
and my mother was an excellent normal mother. I
had a normal childhood.
In answer to specific questions, answers with ‘I don’t
remember’ (cannot give details)
I am comfortable without close emotional
relationships. I like being on my own. It is very
important for me to feel independent and selfsufficient, and I prefer not to depend on others or
have others depend on me.
Or ‘my parents were excellent parents. What’s all
this got to do with the RTA?’
PREOCCUPIED NARRATIVE
My father was mad. He didn’t like me.
He’d always say ‘don’t ever talk to me that
way again’. And Mummy never said
‘don’t’ to him. (Talking as if parents were
actually present).
I want emotionally close relationships, but I
find it difficult to trust others completely, or
to depend on them. I worry that I will be
hurt if I allow myself to become too close to
others.
PREOCCUPIED NARRATIVE
OR
I want to be completely emotionally
intimate with others, but I often find that
others are reluctant to get as close as I
would like. I am not comfortable being
without close relationships, but I sometimes
worry that others don’t value me as much
as I value them. I find it intolerable when
people let me down.
UNRESOLVED/DISORGANISED
NARRATIVE
At times I fall apart, so I can’t depend on
myself. My child drives me crazy. I flip out
whenever he gets upset. I feel like I m
falling apart when he resists me. I feel like I
become at first frightened and frozen, and
then I’m afraid something will snap and I’ll
scream or worse, I’ll hit him. I feel like I am
losing my mind. Sometimes I just get stuck
and I’m unable to move.
UNRESOLVED/DISORGANISED
NARRATIVE
My Dad was scary. If I didn’t eat all my
food he would scream at me and banish
me to my room. Sometimes he would hit
me with his belt. His face was very
frightening when he was like that. Then
later, he would come to my room and get
into my bed and hold me and tell me he
loved me. And I felt very good and safe in
his arms.
DAVID WALLIN, 2007
 Secure/Autonomous
Attachment
Free to connect, explore and reflect
 Avoidant/Dismissive Attachment
Not-so-splendid isolation
 Ambivalent/Preoccupied Attachment
No room for a mind of one’s own
 Disorganised/Unresolved Attachment
Scars of trauma and loss
DIANA FOSHA, 2000
 Secure
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Attachment
Affective competence
Feeling and dealing (while relating)
Capable of auto- and interactive
regulation
‘I’m OK’
DIANA FOSHA, 2000
 Insecure
Dismissive (Avoidant)
Attachment
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Not Feeling but Dealing
‘Goes on automatic’, eradicating feelings
in order to cope.
Less capable of interactive regulation
I’m FINE, Really!’
DIANA FOSHA, 2000
 Insecure
Preoccupied
(Ambivalent/Resistant) Attachment
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Feeling but Not Dealing
Being overwhelmed with feeling and
unable to cope
Capable of interactive regulation but not
easily soothed
Less capable of auto-regulation
‘I’m dying, help!’
DIANA FOSHA, 2000
 Disorganised
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Attachment
Not Feeling and Not Dealing
Alternates between hyper- and hypoaroual
Not capable of auto- or interactive
regulation
‘I’m not sure’
ATTACHMENT CATEGORIES
 Research
on attachment offers a
powerful tool
 But, each person is a one-of-a-kind
 Honouring uniqueness is essential
 But when we can ‘name it we can tame
it’!
POSSIBLE PROBLEMS
CREATED BY
ATTACHMENT
PATTERNS IN EMDR
PROTOCOL
HISTORY TAKING :
CLIENT’S COMMUNICATION
 SECURE
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clients communicate
Truthfully and succinctly while remaining
relevant
Talk thoughtfully and with vivid affect
Are capable, even when absorbed in
strong feeling, of staying connected
Are mindful of the purpose of history taking
Therapist feels connected with client and
optimistic about treatment
HISTORY TAKING
 DISMISSIVE
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clients :
Have a hard time being coherent and
collaborative
Have trouble being truthful, often failing to
support, and may contradict, what they
assert
Are over succinct
‘Don’t remember’ attachment-related
experiences or needs for connection
HISTORY TAKING
 DISMISSIVE
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clients
Often have little to say about the difficulties
that bring them to therapy
The past does not influence the present
Don’t need others for anything
Often come to therapy because partner
thinks they have a problem
Cannot describe any situation from before
turning, say, 15
HISTORY TAKING
 DISMISSIVE
clients :
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Express discomfort with history-taking
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Therapist feels frustrated as taking a history
feel like pulling teeth and case
conceptualisation becomes very difficult
HISTORY TAKING
 PREOCCUPIED
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clients :
May be truthful but are rarely succinct
When asked about family patterns, they
seem to unravel and become tangential
May start to describe past situation and slip
into what happened last week
Can easily become emotional and
overwhelmed during history taking
HISTORY TAKING
 PREOCCUPIED
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clients:
Become preoccupied during history taking
Suddenly the adult tone shifts into a
desperately unhappy forlorn little boy
Therapist feels swamped by client’s
emotional responses during history taking
HISTORY TAKING
 DISORGANISED
taking :
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clients, during history
May demonstrate sudden changes in
speech
Or fall silent for 2 minutes in mid-sentence
and then continue on an unrelated topic
May give extreme attention to details
surrounding loss
Indicate that a deceased individual is
simultaneously dead and alive
HISTORY TAKING
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DISORGANISED clients
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May place the timing of an event, i.e. death, at
several widely separated periods
May indicate that they were responsible for the
loss where no material cause is present
May claim to have been absent at time of a
traumatic event and then a bit later claim to
have been present
May describe an extremely traumatic event in
flat tone and eerie detachment, when 5
minutes previously the client had been
engaged and emotionally available
HISTORY TAKING

DISORGANISED client
 Therapist
feels fragmented and unable to get
a clear picture of client’s history
 Case conceptualisation becomes a
challenge!
 Creating a relationship in which the client can
feel safe becomes a lengthy and fraught
process
PREPARATION PHASE
 SECURE
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clients :
Can engage in the Safe Place exercise with
ease
Generally do not need resource installation
exercises as they are resilient enough
Can collaboratively select targets for EMDR
processing with therapist
PREPARATION PHASE
 DISMISSIVE
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clients :
Generally reject Safe Place and RDI
exercises
Cannot self soothe
Don’t allow anything ‘good’ to come their
way from the therapist
SP and RDI can lead to internal
physiological distress or client reports no
observable response
PREPARATION PHASE
 DISMISSIVE
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clients
Are either devaluing of resource work
Or idealising
Or controlling
Target selection is thwarted by the client
‘not remembering’ any disturbance from
the past
Therapist works hard to identify possible
memories for targeting which are rejected
as not eliciting any emotion by the client
PREPARATION PHASE

PREOCCUPIED clients
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Can work with Safe Place and RDI
But choose a Safe Place with someone else
looking after them
May become overwhelmed with sadness in their
SP (I never got to feel this sense of security with
my mother)
Target selection becomes a challenge as too
many memories of insecurity and cannot
choose a touchstone event
Present and past become entangled in target
selection
PREPARATION PHASE
 DISORGANISED
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clients
Require lengthy preparation
Could easily dissociate whilst doing the SP
and RDI exercises
If one ego states becomes relaxed in the
SP, sabotaging or frightened parts could be
in conflict
RDI with unprepared ego states could also
lead to conflict with other ego states
PREPARATION PHASE
 DISORGANISED
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clients
find target selection a huge challenge
Identifying certain targeted memories
could destabilise ego states which are using
denial as a way of coping
Targets may also be relevant to one ego
state and completely irrelevant to another
ego state
ASSESSMENT PHASE
 SECURE
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clients
Have little or no problem with identifying
the different elements comprising the basic
protocol
Are completely able to collaboratively
identify the elements of the disturbing event
with the therapist
ASSESSMENT PHASE
 DISMISSIVE
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clients
May thwart therapist’s attempts to find a
positive cognition
Similarly, the negative cognition never quite
captures the feeling state
No negative cognition is ‘good enough’
As these clients ‘dismiss’ emotion, no NC will
be acceptable, given that the NC is
elicited to access the emotion inherent in
the event
ASSESSMENT PHASE
 DISMISSIVE
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clients
Identifying the elements of the Assessment
Phase and basic protocol could become a
power struggle with the client
PC may be given a VOC of 7
Wording used to elicit the NC could be a
source of conflict and opposition
Therapist could end up feeling quite
beleaguered
Body sensation completely dismissed
ASSESSMENT PHASE
 PREOCCUPIED
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clients
Could find it hard to settle on one NC and
one PC
NC may spark a distressing feeling state, reassociating the client to the traumatic
event too intensely leading to activation of
dissociative defences
Identifying the NC may be interpreted by
client as the therapist abandoning them
SUDs are often 20+ !
ASSESSMENT PHASE
 DISORGANISED
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clients
Identifying the baseline information in the
Assessment Phase can trigger dissociation
Elements of Assessment Phase for one
target may be very different for different
ego states
Could go into a trance or become terrified
PROCESSING
 SECURE
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clients
Can usually process distressing material,
thoughtfully, with appropriate emotions
and physical sensations, making adaptive
links
Need limited intervention from the therapist
in the form of therapeutic interweaves to
reach adaptive resolution
PROCESSING
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DISMISSIVE clients
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May struggle to get into a mindful state
Answer ‘nothing’ to therapist’s question ; What
do you notice now? Or ‘I’m just watching your
fingers go back and forth’
Need to be told exactly what they are
‘supposed’ to do
‘I’m wondering if this is working
‘Isn’t your arm getting tired?’
‘This seems like a waste of time’
PROCESSING
 DISMISSIVE
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clients
If they access emotion, dismiss it : ‘well, isn’t
that normal?’
‘No I’m not doing well, I never have’
Feedback very limited and brief
Therapist not sure the material is processing
SUDs do not decrease as little emotion is
processed
PROCESSING
 PREOCCUPIED
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clients
Need constant reassurance and comfort of
closeness
Have chronically incomplete sessions
Often get stuck with high levels of emotion
which does not resolve
Move from one distressing incident/memory
to the next without making adaptive links
High emotion may be a way of getting the
therapist to intervene to take care of them
PROCESSING
 PREOCCUPIED
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clients
May process in a very detailed, tangential
and fragmented way
Channels can slip from past to present with
little coherence
Can become overwhelmed and helpless
without resolution, and little adaptive
response to cognitive interweaves offered
by therapist
Endless processing with little resolution
PROCESSING
 DISORGANISED
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clients
Processing is just that, disorganised
Primary, secondary and tertiary dissociation
to be expected
Therapist needs to work very hard to keep
the client connected to present safety
Expect dissociation, projective identification
and counter-transference
EMDR / AIP MODEL
 EMDR
is so much more than an
evidenced-based treatment for PTSD.
 The AIP Model explains why.
 Research and particularly ‘practice
based’ research indicates that EMDR
brings about symptom relief in a great
number of distressing conditions
 EMDR not only brings about ‘state’
changes but also ‘trait’ changes
AIP and
INTERNAL WORKING MODEL
 AIP
has much in common with Bowlby’s
Internal Working Model
 Both assert that early experiences drive
perceptions and responses later in life
 Bowlby stated that the child’s early
experiences with attachment figures
determined the child’s Internal Working
Model, i.e. core beliefs about self, others
and the world
DIAGNOSIS : ATTACHMENT
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No all-encompassing diagnosis for adults
affected by severe attachment-related
trauma
Attachment disorganization in adults is
identified by disorientation, poor logic and
extreme behavioural effects related to
caregiver abuse or major loss
‘Complex Trauma’ is not a formal diagnosis
But outlines the complexity and severity of
symptoms in adults suffering from chronic
abuse by attachment figures
HYPOTHESIS?

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Can EMDR treatment focussing on early
attachment-related trauma change the
attachment status in the affected adult or
child?
If EMDR can successfully reprocess maladaptively stored distressing memories and
create new adaptive associations in the
brain, then targeting early attachmentrelated memories with EMDR should have a
positive impact on the individual’s Internal
Working Model
HYPOTHESIS
 Thus,
improvement of attachment status
through EMDR treatment should


help adult clients to function more
adaptively in relationships
and respond more sensitively to their
children
WESSELMANN & POTTER
(2009)
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3 case studies illustrating pre- and post- EMDR
adult attachment status as measured by the AAI
(Adult Attachment Interview)
All 3 categorised with an insecure or disorganized
attachment status at pre-treatment
Mood and anxiety symptoms related to problems
in current marital and family relationships
Received 10 – 15 EMDR sessions utilising all 8
phases
Following EMDR treatment, all made positive
changes in attachment status
MADRID (2007)
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Describes a method of using EMDR to repair
maternal-infant bonding failures
Case of a mother of a 5 year old girl who
reported only negative emotions re her
experience of being a mother : ‘She drains
me, she’s a pest’
Early negative bonding experiences identified
Standard EMDR protocol used to desensitize
and process these experiences
Mother reported only positive feelings towards
daughter
CASE : ANNIE

30 year old woman with extreme anxiety about 8 month old
baby. Worries about the baby stopping breathing, that the
baby will die and it will be her fault. Feels she is a terrible
mother. She has found the last 8 months ‘too much’ and at
times wishes she was not around.

After 5 EMDR sessions says :
“I am so much more positive now and have gained a much
clearer sense of who I am, and importantly of how my
interactions with the world are shaped. I know I’m an OK
mom, I’m a good enough partner, and if I think I’m not, I really
know why I think this. I feel so good about sharing my
daughter’s ups and downs with her and just being there for her
in a way I never thought was possible”
Sent a picture of baby with card saying “We are both doing
very well these days!”
EFFECTIVENESS OF EMDR ON
ATTACHMENT SECURITY
 Recent
studies provide preliminary
evidence that clients who lack adequate
emotional regulation skills and social
supports can, with support and
preparation, and EMDR treatment :
 Resolve
attachment injuries
 Improve attachment status
 Improve emotional stability
 Improve present day relationships
EFFECTIVENESS OF EMDR ON
ATTACHMENT SECURITY

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More randomized controlled studies are
needed to evaluate changes following EMDR
in adults and children who have experienced
early relational trauma
Wesselman (2012) indicates that more
research is needed to examine effects of
EMDR on

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Attachment status
Relationship stability
Emotional regulation, self-concept, beliefs and
expectations
And Interpersonal behaviours and functioning
EFFECTIVENESS OF EMDR ON
ATTACHMENT SECURITY
 Wesselman
:
“If continued research finds EMDR an
effective method for improving
attachment status, it seems reasonable
to expect that change in attachment
status in parents may increase
attachment security and organization
in their children.”
CASE : ADAM
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2nd of 4 children
When 3 sent with sister and brother to live with
grandmother in Glasgow as parents couldn’t cope
8 years taken with sister and brother to London (not told
where going) to a home for boys and girls
Suffered physical, verbal and sexual abuse
Doesn’t feel much about his experience and ‘just got
on with it’
Became a successful lawyer
Has difficulty in relationships with women. Started a
new relationship and really wants to make this one last
ADAM
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Abandoned by parents
Attached to grandmother but she abandoned
the children by sending them to a home
Avoidant/dismissive attachment style
Secondary and some tertiary dissociation
Has black rages with women
Target : Rejection by teenage son NC :I’m invisible
Floatback : Waiting (over 3 hours) for father to
collect him and brother and Kings Cross Station
11years
ADAM
Incredulity ……. Just waiting
 Waiting. Looking at that boy. How strange they
look. Dressed in horrible thick short trousers and
grey scratchy shirts and big badly fitting boots
 They look hopeless. No life about them
Therapist : ‘Sitting in this chair, the adult you are
today, can you just look at that child’
 Yes
Therapist : ‘Just see this child, just notice whatever
you see (BLS)
 I can’t look at that child. Pathetic!
Therapist : ‘What’s good about not looking at that
child?’

ADAM
I don’t have to see his fear, I don’t want to
see his fear (BLS)
 Well, I can look at him now’
Therapist : ‘When you look at the child, can you
see the child’s feelings?’
 He doesn’t have feelings, he’s not looking at
me. (BLS)
 He’s not looking, not communicating (BLS)
 He’s not anxious to connect at all, he’s just
closed (BLS)

ADAM

Not anxious at all if he is collected or not, so what
(BLS) So what. Voice is distant, a monotone
Therapist asks the client to come back to the room
(CIPOS) (BLS) ‘Come back to the room, We’ll get back
to that boy at the station is a minute. But right now come
back out of it to the room’ (BLS, bringing him back into
therapy room)
‘OK, when you’re ready, close your eyes and just be
drawn back to the boy at the station again. But let
yourself be sure to stay partly here. Just look at that child,
that boy, just see and notice whatever you see (BLS)

I feel irritated with him, I can’t understand why he
does not ask someone, find out what’s happening
(BLS)
ADAM
Feeling twitchy
Therapist invites client to come back to present
safety, then back to the child. ‘Just look at that
child. Is there anything that you know as an adult,
that would be helpful to that child?’
 (long pause) I don’t know, I don’t know how to
comfort him, to get in. I can’t look at him.
Therapist : ‘What’s good about not looking at him?’
 I can’t bear his loneliness, his hopelessness (BLS)
 I feel sad for that boy …. (becomes a bit tearful)
(BLS)

ADAM
Therapist : When you see this child, if you could go back
in time, the man you are today, and go to that boy
and tell him something that would help him with his
sadness, something you know that he doesn’t know,
that would really help him, what would you say to him?’
 I could tell him he deserves better. That he will be
OK (BLS)
Therapist : Do you think that boy has it rough?’
 Yes, yes, I do think he has it rough (BLS)
Therapist: When you look at this boy, how do you feel
about him when you think of this?’
 I feel sad for him because he has no-one taking care
of him (BLS)
ADAM
He has good reason to feel frightened, even angry
(BLS)
 I would never treat my boy, my son like that (BLS)
Tearful.
In this way, the therapist assists the client in
strengthening the part of the self that is oriented to
present reality, and then assists that present-oriented
ego state in witnessing the painful affect held in a
dissociated child ego state. Often the affect within
a child ego state has never been compassionately
observed, either by another person, or by another
part of the self within the personality system
