Developing a Secure Base: Application of Attachment Theory to Clinical Practice

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Developing a Secure BaseApplication of
Attachment Theory to Clinical Practice

• Douglas Goldsmith, Ph.D.
• Executive Director
• The Childrens Center

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Overview

• Foundations of Clinical Practice
• Attachment theory
• Strange Situation
• Internal Working Models
• Reflective Functioning
• Maternal Representations
• Adult Attachment Interview
• Insightfulness
• Treatment implications

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Clinical Practice

• Referral
• Intake
• Assessment
• Treatment
• Discharge

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Good Progress!
Discharge!

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Poor Progress

• Child
• Parents
• System
• Med Management

Blame
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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

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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

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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

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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 Im held I feel warm, safe, and comforted
• Results in a relaxed state so that one can,
  again, begin to explore
  
  Holmes (1993)

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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

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Attachment Classifications

• The strange situation
• Secure 65
• Avoidant 20
• Ambivalent 10
• Disorganized 5-10 (80 maltreated)

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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

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Secure Attachment

• Child feels safe and secure

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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

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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

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Insecure Attachment

• Intense love and dependency
• Fear of rejection
• Irritability
• Vigilance
• Punish their attachment figure for any sign of
  abandonment

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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)

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Disorganized (D)

• Behavior lacks an observable goal
• Look fearful
• Behavior is bizarre
• May try to leave after the reunion or freeze

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Attachment Relationship

• Proximity Seeking
• Secure base effect
• Separation protest

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Attachment Behavioral System
Felt security, love, self-confidence
Attachment figure Near, responsive, attuned
Playful, smiling, Exploratory, sociable
Holmes (1993)
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Attachment Behavioral System
Attachment Figure Distant, Unresponsive Poor
attunement
Avoidant Watchful Wary
Fear Anxiety
Defensive
Visual checking Pleading Clinging
Ambivalent Clinging Angry
Holmes (1993)
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Attachment ProblemsBowlby

• 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

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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

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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

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Internal Working Model

• Based on the childs 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

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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

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Securely Attached Child

• Internal Working Model
• Responsive, loving, reliable caregiver
• Self is worthy of love and attention
• 
  Holmes (1993)

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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

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Development of Relationships

• For a relationship between any two individuals
  to proceed harmoniously each must be aware of the
  others point-of-view, his goals, feelings, and
  intentions, and each must so adjust his own
  behavior that some alignment of goals is
  negotiated.

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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

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Mothers of Secure Infants

• Continuously monitor the infants state
• Accurately interpret the signal for attention
• Act accordingly to meet the infants needs

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Mothers of Anxious Infants

• Monitor the infants state only sporadically
• Inconsistently notice the infants signals
• May interpret the signal inappropriately
• Respond to the signal inappropriately, or tardily

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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)

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Ambivalently Attached Child

• Shows overt aggression toward the inconsistent
  mother
• Dont you dare do that again! but has to cling
  because he knows from experience that she will.
• 
  Holmes (1993)

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Avoidant Child

• Outbursts of unprovoked aggression
• Needs to appease to the mother because the child
  wants so badly to feel close
• Fears shell rebuff him if needs are revealed too
  openly or if anger about abandonment is shown
  too openly
• Holmes
  (1993)

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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 childs
  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

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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)

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Reflective Function

• Allows the individual to make sense of his or her
  own and others psychological experience, to
  enter into anothers experience, to read
  anothers mind
• Allows the child to make others behavior
  meaningful and predictable, and permits him to
  respond adaptively
• Slade (1999)

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Reflective Function

• The mothers capacity to understand the childs
  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)

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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)

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Adult Attachment Interview

• Secure-Autonomous
• Coherent
• Not overwhelmed by emotion
• Show compassion, humor, forgiveness, awareness of
  unconscious, awareness of lack of perfection

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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

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AAI

• Dismissing
• Push aside experiences
• May idealize parents
• Avoid emotional aspects
• Nothing negative in my childhood

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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

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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

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Dyadic Patterns Marvin et al (2002)

• Insecure child Dismissing Parent
• Both partners minimize intimate
  attachment-caregiving interactions
• Miscue Im really more interested in playing
• Independence is highly valued
• Overregulated affect, little emotional
  self-knowledge

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Dyadic Patterns Marvin et al (2002)

• Insecure Child
• Ambivalent/Preoccupied Parent
• Both partners minimize independent exploration
• Child is overly dependent on the parent
• Miscue dont explore, there really is something
  to be anxious about
• Under-regulated affect

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Dyadic Patterns Marvin et al (2002)

• Insecure, Disordered Child
• Disorganized/ Insecure Parent
• Parent fears or becomes angry in response to
  childs attachment behavior and abdicates
  caregiving
• Caregiver has unresolved trauma
• Role reversed relationship

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Maternal Attributions

• Fixed beliefs that the mother has about the child
  beliefs that she perceives as objective,
  accurate perceptions of the childs essence.
• Lieberman (2000)

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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)

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Maternal AttributionsProtective Function

• Child feels adored
• Allow child to cope with self-doubts and feelings
  of despair
• Allow parent to better tolerate self-sacrifices
  that are integral to the parenting process
• Lieberman (2000)

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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)

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Parental Insightfulness

• Parental empathic understanding involves the
  capacity to see things from the childs point of
  view within a balanced, accepting, and coherent
  frame.
• Oppenheim (2000)

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Balanced

• Able to see experiences through their childs
  eyes and make attempts to understand the
  underlying motives
• Talk openly about positive and negative aspects
• Oppenheim (1999)

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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)

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Disengaged

• Lack emotional involvement
• Minimally attempt to understand whats on their
  childs mind
• Oppenheim (1999)
• Video

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Goal of Treatment

• Therapy must help the parents place the childs
  behavior in the appropriate context in order to
  facilitate a response to the behavior that will
  nurture trust and security.

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Ports of Entry

• Developmental Information
• Parent-child relationship
• Projections onto the child
• Lieberman (1999)

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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)

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Circle of SecurityMarvin, Cooper, Hoffman
Powell (2002)

• Childs 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

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Secure Attachment Formula

• Always be bigger, wiser, and kind
• Whenever possible, follow the childs lead
• Whenever necessary, take charge
• Marvin, et al (2002)

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Cooper, Hoffman, Marvin Powell , 2000
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Cooper, Hoffman, Marvin Powell , 2000
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Cooper, Hoffman, Marvin Powell , 2000
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Cooper, Hoffman, Marvin Powell , 2000
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Cooper, Hoffman, Marvin Powell, 2000
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Negative Maternal Attributions

• Determine whether and how mother will respond
  to, misinterpret, or ignore certain behaviors
• Lieberman (2000)

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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

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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?

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Assessment of Parents 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 didnt.
• What gives you the most joy in your relationship?
• What gives you the most pain?
• Where do you turn for emotional support?
• Steele (2003)

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Treatment ConsiderationsExample of Typical
Process

• Parent complains about the childs 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

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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 parents head.

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Treatment ConsiderationsAvoiding 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 childs
  behavior

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Thoughtful Exploration

• Dont jump to your own conclusion, let the
  parents 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.

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Parental Empathic Understanding

• Parental empathic understanding involves the
  capacity to see things from the childs point of
  view within a balanced, accepting, and coherent
  frame.
• Oppenheim (2000)

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Goal of Treatment

• Therapy must help the parents place the childs
  behavior in the appropriate context in order to
  facilitate a response to the behavior that will
  nurture trust and security.

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Circle of Security

• Understanding Secure Base
• Did/Does parent have a secure base?
• Negative Projections
• He doesnt care if Im there for him
• He doesnt need me
• She gets so frantic its like shes crazy!

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Safe Haven

• Comfort level with nurturing
• Emotional/Physical availability
• Negative projections

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Treatment Approaches

• Bridging affect
• Present the childs point of view
• Challenge the parents interpretation
• of the childs behavior

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Secure Base Interventions

• Nurturing
• Anticipating needs
• Helping child regulate emotions
• Parental emotional availability
• Structure and consistency
• Experience of being in ones mind

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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 youll be
  available once the child is calm

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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 lifes greatest
  privileges is just that the experience of being
  held in someones mind.
  Pawl (1995)