/
Attachment in Mental Health and Therapy Attachment in Mental Health and Therapy

Attachment in Mental Health and Therapy - PowerPoint Presentation

phoebe-click
phoebe-click . @phoebe-click
Follow
353 views
Uploaded On 2018-10-06

Attachment in Mental Health and Therapy - PPT Presentation

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: 685567

mentalizing attachment amp secure attachment mentalizing secure amp relationships style aai trauma disorders affect traumatic experiences 2005 unresolved capacity

Share:

Link:

Embed:

Download Presentation from below link

Download Presentation The PPT/PDF document "Attachment in Mental Health and Therapy" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.


Presentation Transcript

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 PatternsSlide21
Slide22

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