Attachment and Related Disorders

1. Attachment and Related Disorders Barbara Morrell, Ph.D. Brigham Young University Inservice Presented to Counseling and Career Center January 13, 2005

2. Attachment The attachment relationship between parent and child refers to those aspects of the relationship that serve to regulate the infant’s stressful arousal or sense of felt security. The quality of regulation of fearful affect available in attachment relationships is foundational to the developing child’s freedom to turn attention away from issues of threat and security toward other developmental achievements such as exploration, learning, and play.

3. Attachment Theory John Bowlby (1969): Attempt to bridge psychological and biological development Rejected Freud’s view that libidinal tie to the mother for need satisfaction is primary. Instead, relationship (binding infant to mother and mother to infant) is primary. Secure attachment to mother essential to normal brain development and relational development

4. Bowlby: As in biological development, role of mother is central to child development: “ If growth is to proceed smoothly, the tissues must be exposed to the influence of the appropriate organizer at certain critical periods. In the same way, for mental development to proceed smoothly, it would appear to be necessary for the undifferentiated psyche to be exposed during certain critical periods to the influence of the psychic organizer—the mother [or other caregiver].”

5. Testing Attachment Theory Mary Ainsworth: Strange Situation • Child is observed for 20 minutes • Caregivers and Strangers enter and leave the room • Recreates the flow of familiar and unfamiliar presence in most children's’ lives • The situation varies in amount of stress, and child’s responses are observed

6. Bowlby (1969) • Mother-infant attachment communications are “accompanied by the strongest of feelings and emotions, and occur with a context of “facial expression, posture, tone of voice, physiological changes, tempo of movement, and incipient action”.

7. Attachment and Neurobiology Ovtscharoff & Braun (Neuroscience, 2001) • “ the dyadic interaction between the newborn and the mother… serves as a regulator of the developing individual’s internal homeostasis. [This] may be an essential promoter to ensure the normal development and maintenance of synaptic connections during the establishment of functional brain circuits.”

8. Attachment and Neurobiology Fonagy and Target, 2002 “Attachment relationships are formative because they facilitate the development of the brain’s self-regulatory mechanism.” Helmeke et al, Cerebral Cortex, 2001 “The functional maturation of limbic circuits is significantly influenced by early socio-emotional experience.”

9. Attachment and Neurobiology • Ainsworth (1967) Attachment is “being built into the nervous system, in the course and as a result of the infant’s experience of his transactions with the mother”

10. Impact of Attachment on the Brain • Helmeke et al, (Cerebral Cortex, 2001) “Positive or Negative emotional experience may carve a permanent trace into a still developing neuronal network of immature synaptic connections, and thereby can extend or limit the functional capacity of the brain during later stages of life.”

11. Neurobiology of Development :Role of the Right Brain Affect Regulation (limbic system) is located in the Right Hemisphere of the Brain Brown and Jaffe, 1975: The right hemisphere can be considered dominant in infancy, for the type of visual and acoustic communication which is relevant for the prelinguistic child.” Matsuzawa et al, Cerebral Cortex, 2001: Infants under 2 years higher right than left hemisphere volume.

12. Right Brain cont. • Right Hemisphere stores a vocabulary for nonverbal affective signals such as facial expressions, tone of voice, and gestures. • RH function: self-regulation—ability to resiliently regulate emotional states in interaction with others..

13. Mother-Infant Communication Transactions happens Right Brain to Right Brain • 80% of Right and Left-handed mothers cradle infant in left arm—easier access to left ear and face (right brain) Schore (1994) • “During eye-to-eye transactions the infant’s maturing right hemisphere is ‘psychobiologically attuned’ to the output of the mother’s right hemisphere”

14. Attachment, Neurobiology, & Self Allan Schore (2003) • “Attachment bonding is critical to development of the right brain systems involved in processing emotion, modulation of stress, self-regulation, and the early origins of the bodily-based implicit self.” • RH Development = Beginnings of the Self? “By casting the Right Hemisphere in terms of self, we have a revolutionary way of thinking about the brain” (Keenan, 2003).

16. Neurodynamics and Psychodynamics Poeggel et al (Neuroscience, 2000) “Neurodynamics parallel psychodynamics in the sense that the disruption of attachment bonds at very early stages of life leads to a regulatory failure and an impaired brain homeostasis.”

17. Mother vs. Father in brain regulation development Schore: • Mother is major regulator for brain growth in 1st year of life. • Father major during second year. (lack of attachment research on Fathers and infants)

18. Implications for Psychological Development Schore • Attachment Theory is fundamentally a theory of the intersubjective origins of the self • Self-organization occurs in context of a relationship with another self, another brain. Devinsky (Epilepsy and Behavior,2000) • RH is dominant for “maintaining a coherent, continuous and unified sense of self.” • Through constant interactions from birth, caregiver is a mirror for child to understand self

19. Attachment Styles Organized Attachment • Secure • Anxious-Ambivalent Insecure • Anxious-Avoidant Insecure Disorganized Attachment • Lack of coherent style at 12-18 months • Leads in later years to: • Controlling/Caretaking Relationship Pattern • Controlling/Punitive Relationship Pattern

20. Secure Attachment Behaviors in Strange Situation • Explore freely while mother present • Engage with Strangers • Visibly upset when mother departs • Happy to see mother return

21. Secure Attachment • Happens when the mother is available and able to meet the needs of the child in a responsive and appropriate manner for the particular child • Accurate mirroring of infant’s nonverbal cues from birth • Responding to stress signals and giving helpful assistance • Secure base from which to explore • Under stress, when appropriate assistance is given, educates the child in how to cope with problems in the future. • Mother’s emotional response helps infant regulate own emotions (becomes wired)

22. Development of Mentalization Peter Fonagy (2005) • For normal development the child needs to experience a mind that has his mind in mind • Able to reflect on his intentions accurately • Does not overwhelm him • Not accessible to neglected children • Mentalization • Capacity for affect regulation and a reflective function • Form of imaginative mental activity: • Perceiving and interpreting human behaviors in terms needs, desires, feelings, beliefs goals • In stressful situation can see self being active and effective: example—5yr old puts trampoline under World Trade Center in his picture after 9/11

23. Anxious-Ambivalent Insecure Behaviors • Anxious of exploration and strangers even when mother present • Extremely distressed when mother departs • Clings to mother when she returns, but seems resentful • Resistant when mother initiates attention

24. Anxious-Avoidant Insecure Behaviors • Avoid or Ignore mother when she is in room • Shows little emotion when mother departs or returns • Does not explore much • Strangers treated same as mother • Shows little emotional range

25. Parenting Syles in Insecure Attachment • Anxious-Ambivalent Insecure • Mother is engaged, but on own terms • Infant’s needs ignored until some other activity is finished • Attention given more through needs of parent • Anxious-Avoidant Insecure • Mother is more disengaged • Child’s needs frequently not met • Child believes communication has no influence on mother

26. Disorganized Attachment Behaviors • First identified at 12 months of age • Erratic Behaviors • Freezing • Huddling on floor • Slowed (under water-like) movements in presence of caregiver when under stress • Disoriented: • Wandering • Confused, dazed expression • In combination with secure strategies • protesting separation • Seeking reunion at return of mother • Ceasing distress when picked up • Key is “No Coherent Strategy”

27. Disorganized (Type D) Parenting Styles • Parental Withdrawal • Negative-intrusive responses • Role-confused responses (seeking comfort from child, etc) • Disoriented responses (Dissociation, drug abuse, etc) • Frightened or frightening responses • Contradictory responses or failure to respond to infant signals

28. Costs of Disorganized Attachment • Loss of Behavioral Control • Experience of unresolved helpless, fearful, or angry affects • Prolonged cortisol elevations • “If child uses caregiver as a mirror to understand the self, the disorganized child is looking into a mirror broken in a thousand pieces.”

29. Animal Studies of Attachment Macaques: • Offspring of mothers who are stressed show elevated levels of cortisol in spinal fluid as adults. • Coplan et al, 1996 • Peer-reared vs. Mother-reared differ in neurotransmitter systems: not synchronized, not stable; blunted system (as in vets); behavior more aggressive • Kraemer & Clark, 1996 Conclusion: Infant open bio-behavioral system takes cues from the environment

30. Human Studies of Attachment In Strange Situation Studies: Main & Morgan, 1996 • 80% of maltreated infants showed Disorganized (Type D) Attachment Spangler & Grossman, 1999 • Inability to organize coherent strategy for eliciting comfort from caregiver is differentially associated with increased release of stress hormones and higher heart rates.

31. Attachment and Psychopathology Research Dissociation Longitudinal Studies (Minnesota and Harvard) • Predictors of Adolescent Dissociation: • Not Physical, Sexual Abuse or witnessing violence • At 24 months of age: Psychological unavailability of caregiver and disorganized attachment (Ogawa et al, 1997); • 39% variance accounted for by Quality of early maternal care (Harvard Longitudinal Study) Conduct Disorder • Attachment difficulties are correlated with early onset Conduct Disorder (Schore, 2005)

32. Attachment and Psychopathology Research Borderline Personality Disorder Predictors of Borderline Personality Disorder (Minnesota and Harvard Longitudinal Studies) • Early referral for caregiver problems • Withdrawal of mother • Genetic Predisposition: Serotonin Transporter variants • Later abuse does add to model BPD predicted by absence of mentalization and hx of abuse (Fonagy, 2005)

33. Conclusions Lyons-Ruth and Hennighausen (2005) • Disorganized attachment processes are early predictors of both internalizing and externalizing forms of psychopathology from the pre-school period onward. • Attachment interacts with individual biological vulnerability to produce a range of psychiatric symptoms.

34. Disorganized Attachment Patterns in Infancy Can Result in • Chaotic/Negative Sense of Self • Impaired development of “Mentalization” (Fonagy) • Capacity for affect regulation and a reflective function • Individual cannot mediate heightened emotional experiences with left brain (goes Limbic) • Experience emotions as “being” instead of “feeling” • Higher levels of stress hormones (cortisol) built into system • Dissociative mental processes: Traumatic memory stored in RB

35. Type D becomes Controlling Attachment Behavior (ages 2-8) • Care-giving Control • Undue attention to parent • Organize, direct, or entertain parent • Aggressor or Victim with peers • Inhibited play • Punitive Control • Undue attention to parent • Escalating non-compliance • Behaviors punish, humiliate parent • Aggressive with Peers

36. Adult Analogs of Type D • Care-Giving Control becomes Helpless Subtype • Unsuccessful attempts to master pain • Pervasive fear • May ID with caregiver: Caregiver helpless/abdicating/unable to protect • Punitive Control becomes Hostile Subtype • Emotionally closed down • Make light of abuse/pain • Global devaluation of caregiver • Can lack empathy with own children • Many People mixed Helpless/Hostile

37. Attachment Applications to College Student Clients • Intense perfectionism that is resistant to tx may reflect Mixed Hostile/Helpless Type • Feels worthless, ashamed, vulnerable, self-critical • Demanding in relationships • People pleasing, but critical when needs not met • Talented, but inhibited in school and career

38. Tx for Hostile/Helpless Type • Identify Emotional/Behavioral Patterns as Adaptation • Caregiving Pattern: • Survival: what would have happened if didn’t • Protect from further harm: being invisible, being “good girl/boy” • Protect self from overwhelming feelings • In service of getting “emotional oxygen”: recognition at times, praise, “crumbs”. • Preserve relationship in family • Self-esteem

39. Tx cont. • Negative Voice • Preserves hope of parental care • Abuse/Neglect must be about me • Semblance of Control • Is relational effort • Is only a story, not truth about self

40. Corrective Emotional Experience in Therapy • Schore: Implicit Communication within the Therapeutic Alliance • In co-created “heightened affective moments” and episodes of interactive repair empathic therapist’s right brain can regulate patient’s right brain negative and positive affective states” • Limbic system is elastic • Therapy induces change in emotion processing regulatory structures. • Limbic system allows brain to adapt and organize new learning • Ruptures in therapy mimic stressful situations for infants • Appropriate, empathic responding can change internal relational representations over time. • Change is in the Repair: Perfect therapists don’t promote change

41. RH and Transference/ Countertransference Shuren & Grafman (Arch.Neurology, 2002) • “The right hemisphere hold representations (interjections, object relations, Bowlby’s IWM’s (Internal Working Models) of the emotional states associated with events experienced by the individual. When that individual encounters a familiar scenario, representations of past emotional experiences are retrieved by the RH and incorporated into the reasoning process.” • Limbic System goes through RB to LB

42. General Therapy Guidelines with Attachment Disordered Clients (BPD) • Needs to be emotionally based to learn emotional regulation • Limitations of verbal therapies • Work on developing “Mentalization” • DBT works well because offers corrective emotional experience and skill-building in mindfulness, mentalization, etc.

43. Therapy Cont. Amini et al (Psychiatry, 1996) Psychotherapy works because it is “an attachment relationship capable of regulating neurophysiology and altering underlying neural structure.” Judith Beck at APA: with Axis II clients CBT doesn’t work until relationship is established and emotional processing accomplished.

44. References Bowlby, J. (1988). A secure base: Parent-Child attachment and healthy human development. New York: Basic Books, Inc. Cashdon, S. (1988). Object relations therapy. New York: W.W. Norton & Company: Melnick, S. (2005). “Trauma and Attachment” Presentation at the Harvard Medical School Attachment and Related Disorders conference, Boston, May 7, 2005. Shore, A. (2003). Affect disregulation and disorders of the self. New York: Norton. Shore, A. (2005). “Recent Advances in the Neurobiology of Attachment: Implications for Interventions and Prevention.” Presentation at the Harvard Medical School Attachment and Related Disorders conference, Boston, May 6, 2005.