A BRIEF ADOLESCENT ENCOUNTER WITH JIM CAIRNS Proximity seeking as primary drive Secure base Internal Working Model to replace structural theories Later theoriststhe attachment system ID: 275097
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Slide1
Attachment in Mental Health and TherapySlide2
A BRIEF ADOLESCENT ENCOUNTER WITH
JIM CAIRNSSlide3
Proximity seeking as primary driveSecure base
Internal Working Model to replace structural theoriesLater theorists:the
attachment system
as the site for
formation of the self
, of agency and of affect regulationCRADLE TO THE GRAVE
BOWLBYSlide4
An “internal working model” contains our expectations for how current and future relationships will unfold, and for how we will experience ourselves and others in that relationship. These are symbolic or representational mud-maps that determine how we perceive, edit, and interpret our relationship experiences. Because these mud-maps shape our response to others, they also shape the actual relationship dynamics, and so become self-reinforcing.
I.W.M.Slide5
McLeod’s “if-then” contingencies
Stern’s “RIGs”Symbolic Attachment (Wallin
)
“drama triangle” (
Liotti
): Persecuter/Rescuer/VictimInternal Working Models are not intra-psychic: they are
intersubjective
I.W.M.Slide6
The Strange SituationCategories of Infant Attachment Behaviour
Secure InfantsAnxious/Avoidant Infants
Anxious/Resistant Infants
AINSWORTHSlide7
Disorganised Infant AttachmentAdult Attachment Inventory
Adult Attachment Styles: - Autonomous/Free/Secure - Dismissing/Avoidant
- Preoccupied/Enmeshed/Ambivalent
- Unresolved (for Loss or Trauma)
Earned Security
Metacognition Fonagy
et’al
“reflective function”, “
mentalizing
capacity”
MAINSlide8
Comfortable in relationship settings. Readily contribute to interdependent relationships as a springboard for engaging in the wider world.
Less distressed by interpersonal conflict. Able to engage in productive, task-oriented conflict.Less preoccupied with the need to elicit positive regard from others or the need to avoid closeness with others.
Secure Attachment Style – Autonomous/FreeSlide9
Desire closeness but become anxiously preoccupied by how others regard them. This can limit their ability to explore the outside world, other relationships or even work and hobbies.
Their ability to develop interdependent and cooperative relationships can also be limited.
Have a need for experiencing acknowledgement, praise, being valued, acceptance, support and being included.
On the other hand, can tend to dislike intrusiveness by others and can mistrust positive relatedness as phony or unreliable. (ambivalence)
Preoccupied/Enmeshed/Ambivalent Attachment StyleSlide10
Compulsively self-reliant, dismissing needs for closeness for selves and others.
May naturally engage in negative or unproductive conflict. Efforts to develop inter-dependant relationships at work and in community compromised by the need to avoid group intimacy.
Likely to
interpret efforts for closeness by others as intrusive and demanding.
Dismissing/Avoidant Attachment StyleSlide11
The person is not the category.
“We’re all individuals” (Brian)“I’m Not”Slide12
The act of reflecting on one’s own mental representations of self and other (and associated feelings); AND – at the same time – being able to reflect upon the other person’s mental representations, feelings, and
intentions.
Moreover, it involves perceiving the connection between one’s mental state and that of the other person.
MentalizingSlide13
A series of studies show that 72% have same attachment classification at 18 months (SS) and at 21 years of age (AAI) (
David,Kaplan,Mayes 2010)
Lifelong Effect of Infant Attachment CategorySlide14
Correspondence between SS and AAI Categories
Secure
Avoidant
Resistant/Ambivalent
Disorganised
Autonomous/Free
Dismissing/Avoidant
Preoccupied/Enmeshed
Unresolved for loss or traumaSlide15
Prompt responsiveness to distress, Non-Intrusiveness, Interactional Synchrony, Warmth
Mid-Range Tracking of Child’s Affect (Beebe and Lachman 2002)Contingent and Marked Mirroring
Containment –
understand the cause of distress
-
do not join in their distress - recognise their intentional stance
Mirroring Meta-Cognitive Capacity
Intersubjectivity
Repeated cycles of
attunement
,
misattunement
, and
reattunement
(
Schore
2008)
REPAIR –GOTTMAN and couples
Optimal Conditions for Secure Attachment – CRADLE TO GRAVESlide16
Intersubjective Experiences
This involves exquisite synchronisation of facial expressions, mirroring of emotions and anticipation of each other’s intentions.
“Mirror neurones”
(Johnson, 2009;
Rothchild
2000) allow each person to know the other from the inside out through associated stimulation of the autonomic nervous systems.
Oxytocin
is released creating a cascade of pleasurable and comforting body experiences.
“Each person’s mind and emotion are attuned to the other’s. Each person knows the other’s mind and recursively knows that he or she exists in this mind.”
(Johnson, 2009,p273)
Slide17
Individuals categorised as “secure” are 3 to 4 times more likely to have securely attached children (van Ijzendoorn1995; Ward & Carlson 1995)
80% of children with Disorganised Attachment (SS) have parents with Unresolved Attachment Style (AAI)Genetics and child temperament are only minor determinants of attachment pattern (
Belsky
et,al
1995, Liotti 2005)Slade 2005, Arnott & Meins 2007:
Attachment style
of caregiver and
metacognitive
ability
of caregiver are predictive of child’s attachment style and meta-cognitive capacity
Intergenerational transmissionSlide18
Secure attachment (AAI)
coorelates with greater intimacy in close relationships (Hazan & Shaver 1993,
Borelli&David
2004)
Insecure attachment (AAI) results in less effective stress management (
Scheidt et,al 2000)Adult attachment behaviour shapes one’s experience of, and behaviour in, group contexts generally. (
Markin
&
Marmarosh
, 2010;
Rom&Mikulincer
2003).
Feeney (
et,al
2008) demonstrated that a person’s attachment style determines how they engage in and shape new relationships with people – in both social and work environments.
Secure attachment (AAI) protects adolescents from risk-taking behaviour (Wills & Cleary 1996)
Adolescents with secure attachment patterns with their parents are more able to launch and create interdependent adult relationships (
Allen&Land
1999,
Noom
et,al
1999).
Adults who experience secure and reliable dependence with their spouse are more able to explore and perform independently away from their spouse (Feeney,2007; Elliott, 2003).
Effect of Attachment Style on Psycho-Social OutcomesSlide19
Disorganised (SS) and Unresolved (AAI) Styles are strongly correlated to disorders of both axes, especially BPD (
Schore 2002, Fonagy
et,al
2006) and PTSD (
Liotti 2005) and eating disorders (david et’al 2010)Avoidant Attachment is associated with
obsessional
,
narcisistic
and schizoid problems (Bouchard
et,al
2008; Wei
et,al
2005)
Preoccupied/Ambivalent Attachment is
asscociated
with borderline and
hystrionic
difficulties (
Schore
2002, Slade 1999, Sable 1997,
Shorey
& Snyder 2006))
Improvements in attachment relationships protect people from and reduce symptoms of Post Traumatic Stress Disorder (Muller &
Rosenkranz
2009; Mills,2008;
Verhaeghe
et,al
2005).
Interrelationship between insecure attachment patterns and mood disorders (Wei
et,al
2005) (West 2002)
Correlation between Reflective Function,
Mentalizing
capacity and disorders of both axes (
Fonagy
et,al
1997, 2006)
Psycopathy
and autism have been described as disorders of menatalization (Fonagy et’al 2006)
Effect of Attachment Style on Mental Health OutcomesSlide20
Mentalized Affect - JuristInterpersonal Affect Regulation
The Dependence-Independence Paradox (Feeney)Positive Dependency – Solomon
Emotion Regulation and Attachment PatternsSlide21Slide22
Poor emotion regulation, poor impulse control, volatility of relationships and self-image,
psychotic symptomsFragile mentalizing capacity vulnerable to social interactions
Primary difficulty is a loss of
mentalizing
arising from failures in early attachment (
Schore, Fonagy et,al
;
Liotti
)
BPD is strongly associated with insecure attachment (only 6-8% are classified as secure) and most strongly associated with Disorganized Attachment (Levy 2005)
Causes are abuse, neglect and gross failures in
mentalizing
responsiveness by parents (
Fonagy
& Bateman,2010)
BPD and Attachment PatternsSlide23
Primary Focus is on emotion regulation – immediate threat to treatment success
Containment – validate their distress - manage your own reactions - validate their intentional stance
Reinstate
mentalizing
when it is lost or to help maintain it when loss is immanent
Maintain an active, collaborative, not-knowing stanceAsk “what” questions rather than “why”Match intervention to mentalizing
capacity, de-prioritise insight and interpretation and cognitive-based prescriptions
Actively manage enactments and schisms in the alliance
Introduce alternate representations tentatively and collaboratively
Be up front about your own thoughts and feelings as a way of introducing alternative constructions
Tight-rope of workable tension and emotion storms
Switching focus between mental states of self and other
BPD and REMISSION
BPD, Attachment and
Mentalized
Based Treatment (MBT)Slide24
Developmental Thread from Disorganised Attachment (SS) to Unresolved Attachment (AAI) and Dissociative Disorders (including DID) and vulnerability to PTSD after a traumatic incident (
Liotti 2004, Steel & Steele 2003)Dissociative phenomena found from childhood through adulthood in Disorganised Attachment
Traumatic experiences trigger the attachment system: all insecure attachment types more vulnerable to PTSD
in unresolved attachment, attachment traumas are triggered and vulnerability to dissociative symptoms are amplified including peri-traumatic dissociation
Trauma, Dissociative Disorders and Attachment PatternsSlide25
Qld Ambulance policyFonagy
et,al: attachment trauma includes abuse and neglect but also failures of responsive mirroring
Viscious
Cycle of Traumatic Symptoms and current Attachment dynamics – implications – one context of trauma reinforces the other context of trauma
Attention to attachment system must take primacy over exposure attempts
i.e. heuristic attention to :a
) material from childhood attachment
traumas
b
) material from current
attachment
traumas
c
) optimising secure attachment experiences in the current therapeutic
setting
Supporting
Mentalizing
when it is at risk, reinstating
mentalizing
when it is lost.
Liotti
: delayed memories and delayed dissociation when significant change in relational
Trauma, Dissociative Disorders and Attachment PatternsSlide26
Secure BaseThe primacy of emotions
Mentalizing EmotionsInterpersonal and Personal Affect Regulation
The tight rope of working with Attachment Systems
Managing
Enactments,Managing
Affect Storms, Transference RepairProviding Experiences of Secure Attachment – Mirroring, Containment,
Intersubjectivity
as opposed to Re-Parenting
Focussing on Enhancing
Mentalizing
Capacity
Modifying Interventions to match their
Mentalizing
Capacity
Keeping an eye on the Systemic
Principles of Containment
Softening (Johnson) Responses
Essentials for TherapySlide27
IMPLICIT, “Right Brain” INTERSUBJECTIVITY most crucial with severe disturbance (Schore
2008)“Not only is the therapist being unconsciously influenced by a series of slight and, in some cases, subliminal signals, so also is the patient. Details of the therapist’s posture, gaze, tone of voice, even respiration, are recorded and processed. A sophisticated therapist may use this processing in a beneficial way, potentiating a change in the patient’s state, or in a addition to, the use of words.”
Schore
, 2008
Essentials for TherapySlide28
Interlocking Vulnerabilities:
Dyadic Mentalizing
Explicit/Defensive Behaviour
Underlying VulnerabilitiesSlide29
David is a 55 year-old ambulance driver , 25 year career
He has not previously had trouble with traumatic experiences until recently. He is being troubled by fragmented memories from various jobs over the years
He is experiencing depression and a difficulty in maintaining concentration. He has stopped going to his woodworking club and dreads going to work and feels antipathy toward managers and supervisors. He particularly resents heaving to bear the brunt of his work while he is required to constantly “babysit” new paramedics.
He feels a pervading sense of being on his own with his experience, believing no one cares about his plight. He feels the ambulance service is oblivious to his experience. He deplores the loss of camaraderie and support that had come with years of organisational restructuring and emphasis on productivity.
The event that appears to have triggered his difficulties was a job where he attended the death of an elderly woman from a heart attack. He remembers vividly the scene: Beside the body was her adult son, crying uncontrollably, begging for him to help.
CASE STUDYSlide30
This scene exposed David’s grief for the loss of his mother 12 months before - grieving he had deferred because of his ambivalence toward his mother (indicating attachment difficulties).
Therapy familiar approaches such as titrated exposure, unpacking his complicated grieving and boundary marking between his and other people’s trauma
what David reported to be most useful was including his wife in therapy sessions and working on the way difficult emotions were dealt with in that relationship
Once he had re-established this relationship as a secure base and as a context for affect regulation, David was psychologically available for working on his issues of traumatic stress and unresolved grief.
He was able to reengage in his workplace, was less preoccupied by the responsiveness of colleagues and the organisation in general. He was able to access more benign representations of others at work – that they too were just trying to get by with demands and new realities in their own way.
CASE STUDY