Attachment in Mental Health and Therapy

1. Attachment in Mental Health and Therapy

2. Applying Attachment Theory The FOUR ESSENTIAL DIMENSIONS 1) SELF - in - relation - to – OTHER (Symptoms are seen as imbedded in the “Attachment System”) 2) The Primacy of Emotions 3) Promoting Metacognition 4) Provision of a Secure Base and Safe Haven

3. CAROL Carol is a 27 year old woman who is referred to you because of her depression, panic attacks and eating problems, which consists of erratic bingeing but without vomiting. She binges as a way, as she puts it, “of shutting down my feelings”. It is only when she binges that she can feel like “nothing matters”. Her depression has worsened after the break-up of a relationship 18 months ago. Since then she has felt worried about her future, fearing that her life is going nowhere. She says she fears loneliness the most. Carol finds it difficult to sustain relationships. Her relationship with her current boyfriend has been on again-off again for some time. She feels people are often trying to get away from her. She has been told by friends that she can be “too much”.

4. She recognizes her sensitivity to feeling easily rejected eg. friends not inviting her She calls and texts her boyfriend several times a day and worries if she can not get hold of him Prior to the first session Carol phoned several times to confirm she was coming. Her father died when she was young. She says her mother coped very well as a single mother and developed a very successful business as she got older. She berated herself for not being able to “get her act together” like her mother. In ensuing sessions it becomes apparent that Carol could be rather hostile toward others if they were not available to her when she needed them. When this happens, Carol describes dissociating herself from her feelings, retreating into a “nothing matters” state which she recreates in her eating binges. Carol is able to recognize that her biggest fear is loneliness, and that bingeing protects her from feeling the panic of impending abandonment.

5. Carol is a 27 year old woman who is referred to you because of her depression, panic attacks and eating problems, which consists of erratic bingeing but without vomiting. She binges as a way, as she puts it, “of shutting down my feelings”. It is only when she binges that she can feel like “nothing matters”. Her depression has worsened after the break-up of a relationship 18 months ago. Since then she has felt worried about her future, fearing that her life is going nowhere. She says she fears loneliness the most. Carol finds it difficult to sustain relationships.Her relationship with her current boyfriend has been on again-off again for some time. She feels people are often trying to get away from her. She has been told by friends that she can be “too much”. She recognizes her sensitivity to feeling easily rejected eg. friends not inviting her She calls and texts her boyfriend several times a day and would worry if she could not get hold of him Prior to the first session Carol phoned several times to confirm she was coming. Her father died when she was young. She says her mother coped very well as a single mother and developed a very successful business as she got older. She berated herself for not being able to “get her act together” like her mother. In ensuing sessions it becomes apparent that Carol could be rather hostile toward others if they were not available to her when she needed them. When this happens, Carol describes dissociating herself from her feelings, retreating into a “nothing matters” state which she recreates in her eating binges. Carol is able to recognize that her biggest fear is loneliness, and that bingeing protects her from feeling the panic of impending abandonment.

6. INTERNAL WORKING MODEL • 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.

7. INTERNAL WORKING MODELS • 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

9. Attachment Style Questions (Iemma, Target, Fonagy 2011) • It is easy for me to become emotionally close to others. I am comfortable depending on them and having them depend on me. I don’t worry about being alone or having others not accept me. (= “Secure” quadrant) • I am uncomfortable getting close to others. I want emotionally close relationships, but I find it difficult to trust others completely, or to depend on them. I worry that I will be hurt if I allow myself to become too close to others. (= “Fearful” quadrant)

10. c) I want to be completely emotionally intimate with others, but I often find that others are reluctant to get as close as I would like. I am uncomfortable being without close relationships, but I sometimes worry that others don’t value me as much as I value them. (= Preoccupied quadrant) d) I am comfortable without close relationships. It is very important to me to feel independent and self-sufficient, and I prefer not to depend on others or have others depend on me. (= Dismissive quadrant)

11. The Problem as part of the Client’s Attachment System

12. Describing the Self – Other Representation that is meaningfully connected to the presenting symptoms/difficulties • Ask yourself: How does the client experience themselves in relation to others? • Identify who does what to whom and the associated affect. • How is this internalised self-other representation manifest in their outer life? • How might their representations of self/others influence and be influenced by current relationships? • How does this internalized self-other representation manifest themselves in relation to you, the therapist?

13. Interpersonal-Affective Focus (IPAF)

14. Defensive Function of this Interpersonal Configuration Ask Yourself: What is the client afraid of or trying to avoid in themselves? What are the possible consequences of change? What does their representation of themselves and others protect them from experiencing? What would happen if the client’s construction of OTHER altered? What would this mean for the client? What would be required of them? What would happen if their construction of themselves changed?

15. CAROL’s Interpersonal-Affective Focus (IPAF)

16. CAROL’s Interpersonal-Affective Focus (IPAF)

17. 2) The Primacy of Emotions Emotions Precede Cognitions Focussing on and Reflecting Upon Emotions is a necessary precondition for the elaboration of new cognitive constructs

18. Mentalized Affectivity • Elliot Jurist’s 2005 3 part process • Identifying Affects - naming - distinguishing 2) Processing Affects - modulating - refining 3) Expressing Affects - outward expression - inward expression

19. The 80-20 Rule

20. Fonagy, Iemma, Target 2011 Focus on Emotions • Focus on how some affects need to be kept in check by defences • Focus on how some affects function as defences (=EFT ) • Focus on how emotions are managed or discharged

21. Fonagy, Iemma, Target 2011 Aims of Work on Emotions • Identify what the client feels, encouraging them to stay with a current feeling as it emerges in the session • Help them to communicate their feelings more effectively. • Build a capacity for the client to connect their emotions to the IPAF

22. Interpersonal-Affective Focus (IPAF)

23. Emotionally Focussed Therapy • Primary Emotions • Secondary Emotions • Instrumental Emotions Heightening and Softening Interventions

24. Sue Johnson VIDEO – Heightening and Softening

25. EFT RISSSC Interventions with Emotions R Repeat key words or phrases I Images that evoke emotions S Simple, concise phrases are powerful S Soft, soothing tone to create safety S Slow the pace to deepen emotional experience C Client’s phrases are used

27. Interlocking Vulnerabilities Explicit/Defensive Behaviour Underlying Vulnerabilities OTHER CAROL

28. 3) Promoting Meta-Cognition 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. (benign intentions) Moreover, it involves perceiving the connection between one’s mental state and that of the other person. INTENTIONAL STANCE

29. Failures in Mentalization(Fonagy et.al 2008) Psychic Equivalence Mode World=Mind, ideas are too “real” constructs are not distinguished from external reality that they represent eg. dreams, flashbacks, paranoid delusions Pretend Mode ideas are not real enough authentic feelings do not accompany thoughts can make wild assumptions about mental states of others, “hypermentalizing” “destructively inaccurate mentalizing” Teleological Mode Mental states are comulsively acted out Only actions and their tangible effects count eg. self harm, violence

30. Interventions that Enhance Mentalizing Capacity • An inquisitive, “not knowing” stance • Exploring interactions and self-experiences from multiple perspectives • Validating their experience before offering alternate perspectives • Letting client know what you are thinking and inviting them to correct it • Two hands

31. Interventions that Enhance Mentalizing Capacity • Identify a break in mentalizing • Rewind to a moment before the break • Explore the current emotional context (client-therapist dynamic?) • Make contrary moves When they are overly introspective, invite them to consider another mind When they are excessively focussed on others, invite them to focus on his or her own mind

32. Features of Good Mentalizing

33. Jon Allen: Some people need to feel more about their thinking. Some people need to think more about their feelings.

34. What interventions come to mind with respect to Carol?

35. Bateman - you tube role play • http://www.youtube.com/watch?v=ilpD1ZtdbFs

36. Scenario - Carol Carol comes to her session this week with her interpersonal narrative of the week. For some time she has started seeing her ex-boyfriend again, though she is still plagued by fears that he is not interested and committed to her. She seems to cope with this fear by not caring. When asked about her commitment to the relationship, Carol shrugs and says she doesn’t know, that it just all feels “too much hassle” sometimes. She describes a recent event where they both went out night clubbing with their own separate friends, but planned to catch up together later in the night. Carol texted him several times but he failed to respond until 30 minutes later. Carol texted saying he was “an asshole that couldn’t be trusted”, that he “can just go and shag some other girl because she was over it.” Her boyfriend tried to reassure her that he wasn’t with anyone else, but the angrier Carol’s texts became the more he decided he’d had enough and told her so. The next day, they Carol went over to his house to sort things out but they became embroiled in an argument about why he hadn’t made more of an effort. Carol complained that he just gave up to easily.

37. 4) Providing a Secure Base and Safe Haven Mentalizing capacity can only be fostered in the context of a secure attachment environment

38. 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 • Tronic – 1/3rd attunes, 13rd misattuned, 1/3rdreattuning

39. The Primacy of INTERSUBJECTIVITY INTERSUBJECTIVITY = “The phenomenon of two minds being under mutual influence.” 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) Therefore meaning and construction is not given to the client, they are co-constructed.

40. Stern’s Moments of Meeting “This involves the mutual interpenetration of minds that permits us to say, ‘I know that you know that I know’ or ‘I feel that you feel that I feel’. There is a reading of the contents of the other’s mind. Such readings can be mutual. Two people see and feel roughly the same mental landscape for a moment at least. These meetings are what psychotherapy is largely about.” (Stern 2004, p75)

41. Hermeneutic Circle (Dilthey)

43. Emergence Vs Structure • What is meaningful is what emerges intersubjectively between client and therapist • Meaning is co-constructed • This approach “feels very different from listening to a CBT session because of the more emergent quality of the patient-therapist dialogue.” (Fonagyet,al 2010) • Not Knowing (Harlene Anderson) • Tentative Interpretation

44. Kohut “….transmuting internalization of the self-object functioning of the therapist” IDEALIZING MIRRORING TWINSHIP

45. REPAIRING SCHISMSSix Steps of Actively Managing Disruptions in the Alliance(Fonagy and Bateman, 2010) • 1) Validate their feelings about what has happened. • 2) Explore the sequence of interaction in a not-knowing way • 3) Accept your own enactment or part in the interaction: even partial responsibility • 4) Collaborate in coming to a joint understanding of the Interaction • 5) Present alternate perspectives • 6) Monitor reactions – theirs and yours

46. “We are faced with a paradox: in the present mental healthcare climate, one needs manuals to be practicing evidence-based treatment; yet developing a manual to an extremely high level of specificity would undermine precisely what we are striving to cultivate: mentalizing.” (Fonagy, Allen, Bateman 2008,p169)

47. Carol What are the potential issues for the client therapist relationship?