Attachment in Mental Health and Therapy

1. Attachment in Mental Health and Therapy

2. A BRIEF ADOLESCENT ENCOUNTER WITH JIM CAIRNS

3. BOWLBY • Proximity seeking as primary drive • Secure base • Internal Working Model to replace structural theories • Later theorists:theattachment system as the site for formation of the self, of agency and of affect regulation • CRADLE TO THE GRAVE

4. I.W.M. • 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.

5. I.W.M. • McLeod’s “if-then” contingencies • Stern’s “RIGs” • Symbolic Attachment (Wallin) • “drama triangle” (Liotti): Persecuter/Rescuer/Victim • Internal Working Models are not intra-psychic: they are intersubjective

6. AINSWORTH • The Strange Situation • Categories of Infant Attachment Behaviour • Secure Infants • Anxious/Avoidant Infants • Anxious/Resistant Infants

7. MAIN • Disorganised Infant Attachment • Adult Attachment Inventory • Adult Attachment Styles: - Autonomous/Free/Secure - Dismissing/Avoidant - Preoccupied/Enmeshed/Ambivalent - Unresolved (for Loss or Trauma) • Earned Security • Metacognition • Fonagyet’al “reflective function”, “mentalizing capacity”

8. Secure Attachment Style – Autonomous/Free 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. 

9. Preoccupied/Enmeshed/Ambivalent Attachment Style 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)

10. Dismissing/Avoidant Attachment Style 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.

11. The person is not the category. “We’re all individuals” (Brian) “I’m Not”

12. Mentalizing 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.

13. Lifelong Effect of Infant Attachment Category • 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)

14. Correspondence between SS and AAI Categories • Secure • Avoidant • Resistant/Ambivalent • Disorganised • Autonomous/Free • Dismissing/Avoidant • Preoccupied/Enmeshed • Unresolved for loss or trauma

15. Optimal Conditions for Secure Attachment – CRADLE TO GRAVE • 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

16. 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)

17. Intergenerational transmission • 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 (Belskyet,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

18. Effect of Attachment Style on Psycho-Social Outcomes • 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 (Scheidtet,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, Noomet,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).

19. Effect of Attachment Style on Mental Health Outcomes • Disorganised (SS) and Unresolved (AAI) Styles are strongly correlated to disorders of both axes, especially BPD (Schore 2002, Fonagyet,al 2006) and PTSD (Liotti 2005) and eating disorders (davidet’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; Verhaegheet,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 (Fonagyet,al 1997, 2006) • Psycopathy and autism have been described as disorders of menatalization (Fonagyet’al 2006)

20. Emotion Regulation and Attachment Patterns • Mentalized Affect - Jurist • Interpersonal Affect Regulation • The Dependence-Independence Paradox (Feeney) • Positive Dependency – Solomon

22. BPD and Attachment Patterns • Poor emotion regulation, poor impulse control, volatility of relationships and self-image, psychotic symptoms • Fragile mentalizing capacity vulnerable to social interactions • Primary difficulty is a loss of mentalizing arising from failures in early attachment (Schore, Fonagyet,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)

23. BPD, Attachment and Mentalized Based Treatment (MBT) • 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 stance • Ask “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

24. Trauma, Dissociative Disorders and Attachment Patterns • 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

25. Trauma, Dissociative Disorders and Attachment Patterns • Qld Ambulance policy • Fonagyet,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

26. Essentials for Therapy • Secure Base • The primacy of emotions • Mentalizing Emotions • Interpersonal and Personal Affect Regulation • The tight rope of working with Attachment Systems • Managing Enactments,Managing Affect Storms, Transference • Repair • Providing 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

27. Essentials for Therapy • 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

28. Interlocking Vulnerabilities: Dyadic Mentalizing Explicit/Defensive Behaviour Underlying Vulnerabilities

29. CASE STUDY • 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.

30. CASE STUDY • 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.