Attachment and Mentalizing: Helping Children with Attachment
Trauma
Chris Taylor MSc(Psych)
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Seminar Outline
Recap Attachment
Theory
Think about Models of
attachment
The effects of
Attachment trauma
Introduce Mentalizing
Experiential activity
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Multi-Level Explanation
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“There’s nothing so useful as a good theory” – Kurt Lewin
Biological and evolutionary
basis
Behavioural level –
patterns of relating
Cognitive level –
internal working model
Affective level – emotional content of
relationships / secure base
What is Attachment?
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Unable to cling, unable to move themselves, human infants are born supremely adapted for sociability.
Attachment Theory Proposes
A biologically-based need for relationships across the lifespan Forming and maintaining attachments is a key
biologically based developmental task
Attachment to a significant “other” provides support and protection against stress and distress
Early bond with primary carers influences future, intense, reciprocal relationships
Relationships with a few specific people are crucial for an child’s developing brain
Without these relationships, important neural networks are not laid down
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Shared Minds Build Bonds of Affection
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The human capacity to represent ourselves and others as thinking, wishing, feeling beings does not arrive as a consequence of maturation, but is a developmental achievement rooted in the quality of early relationships.
Develops from the inherent capacity to have a visceral reaction to each other’s actions, mishaps and feelings
Seen in a new-born baby’s rudimentary capacity to influence their mother
7-9 months - a growing awareness of that inner, subjective experiences can be shared with someone else
Shared Minds Build Bonds of Affection
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Bonding Caregiver ‘s feelings and capacity to: • Nurture • Be responsive • Protect
I love you I’ll take care of you You are important to me I’ll keep my eye on you I’ll keep you warm I’ll keep you fed I’ll keep you clean
Messages given
You’ll take care of me I need to stay close to you I look to you to take care of me You’ll teach me about myself and the world I’m OK I’m loveable
Attachment An affectionate bond that endures through space and time and joins individuals emotionally. A psychological bond to a person who provides protection
Child internalizes image of themselves in their caregiver’s mind Internal Working Model of Attachment learnt from experiences of exploration and protection (first 18 months of life)
Internal Working Model
Exerts a direct influence over behaviour and responsiveness in all settings
Failure to accurately mirror a child’s mental states is responsible for establishing impairments in the child knowing their self and empathising with others
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Models of Attachment
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Negative About Other
Positive About Other
Positive About Self
Negative About Self
Secure Predictable and attuned caregiving Caregiver trusted to support exploration and provide safety “because I’m worth it”
Insecure – Ambivalent Unpredictable and inappropriate caregiving. Wants to increase caregiver responsiveness, but angry because protection can't be relied upon
Insecure – Avoidant Predictable danger (e.g. of being neglected) Learnt not to rely on caregiver
Disorganized Attachment figure is also the source of fear Incompatible behaviours: flight and proximity seeking Context-dependent failure of mentalisation
Models of Attachment
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“New brain”: Imagination, Planning, Rumination, Integration
“Old brain”: Emotions, Motives, Relationship seeking creature
Implicit emotional memory of connectedness “I trust you, you support me” “I’ll manage alone” “I want support, but I’m angry with you” “I fear you, but cannot tolerate separation”
Models of Attachment
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“New brain”: Imagination, Planning, Rumination, Integration
“Old brain”: Emotions, Motives, Relationship seeking creature
Implicit emotional memory of connectedness “I trust you, you support me”
Models of Attachment
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“New brain”: Imagination, Planning, Rumination, Integration
“Old brain”: Emotions, Motives, Relationship seeking creature
Implicit emotional memory of connectedness “I trust you, you support me” “I’ll manage alone”
Models of Attachment
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“New brain”: Imagination, Planning, Rumination, Integration
“Old brain”: Emotions, Motives, Relationship seeking creature
Implicit emotional memory of connectedness “I trust you, you support me” “I’ll manage alone” “I want support, but I’m angry with you”
Models of Attachment
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“New brain”: Imagination, Planning, Rumination, Integration
“Old brain”: Emotions, Motives, Relationship seeking creature
Implicit emotional memory of connectedness “I trust you, you support me” “I’ll manage alone” “I want support, but I’m angry with you” “I fear you, but cannot tolerate separation”
A “Hidden” Problem…
Secure attachment is a basic human need of all infants, but is not always met
Children can experience high levels of stress and anxiety without necessarily showing outward displays of distress
We need to do three things 1. Improve the general understanding of the issue
of attachment 2. Improve the skills and awareness of the
workforce so that attachment problems are recognised and where possible addressed
3. Improve access to specialist support where necessary
Growing evidence for the usefulness of MZ-based approaches (Sadler et al 2006; Suchman et al, 2008; Schechter & Willheim, 2009).
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Prevalence of Disorganized Attachment
15%
25%
40% 48%
80%
Overall Poverty Substance -misuse
Maltreatment Maltreatment
van Izjendoorn et al 1999 Carlson,Cicchetti et al(1989); Lyons-
Ruth (1996)Disorganized attachment
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Brains Under Attack!
Risk of dysregulation at bio-behavioural level
For most children, cortisol levels drop throughout the day to near zero at night
Cortisol levels relate to stress
These children show very high levels of cortisol throughout the day
In the context of early childhood, attachment trauma means acquired brain injury as a result of unregulated stress induced in the attachment relationship
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Brains Under Attack!
Cortisol released in stress travels into the brain and binds to the receptors inside many neurons
Through a cascade of reactions, this causes neurons to admit more calcium through channels in their membrane.
In the short-term, cortisol helps the brain to cope with the life-threatening situation
However, if neurons become over-loaded with calcium they fire too frequently and die – they are “excited” to death.
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Brains Under Attack!
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We need a general direction….
Brain is now wired like this
Therapeutic task…to rewire the brain
How????
Mz approach is rooted in Attachment Theory
Provides a “compass” to reach the hard to reach
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The Therapeutic Task
A “companion for exploration” (Bowlby)
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Thinking about Attachment
Thinking about Trauma
Thinking about Minds (Mentalizing)
Mentalizing
The active, imaginative process by which we make sense of our selves as persons whose actions are based in mental states
This process comes so naturally to us that we easily overlook its significance
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Broad Scope of Mentalizing
Metacognition; Mindfulness
Emotional Literacy
Theory of Mind Empathy
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Others
Feelings Thoughts
Self
Mindful Mind: Mentalizing Self
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“Old brain”: Emotions, Motives, Relationship seeking creature
Emotional memory of connectedness
Mindful mind
“New brain”: Imagination, Planning, Rumination, Integration
Mentalizing Other: Curiosity
To understand therapeutic work we must pay careful attention to mentalizing and the conditions under which this basic human capacity becomes impaired
Siegel: “Integration develops when we focus our mind on the internal nature of own experience (insight) and on internal nature of some-one else’s experience (empathy)”
Three Sub-Domains of Mentalizing
Mentalizing
Self – Other Implicit – Explicit
Implicit: nonconscious, nonverball,
nonreflective (e.g. mirroring another)
Explicit: interpretive, conscious, verbalised,
reflective
Cognitive - Affective
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“We must keep in mind that the mental states perceived and the process of perception are suffused with emotion” – Peter Fonagy
Why was she so abrupt with me?
Why have I binged on that ice-cream?
Responding to other’s emotions…
Nodding sympathetically
Mentalizing Spectrum
• Identifying emotion, controlling impulses Being self-aware
• Emotions regulated, paying attention, thinking about thinking and feeling Flexible thinking
• Empathy, support and attunement; Distress tolerance Thinking whilst feeling
• Clarification, elaboration and challenge Curiosity
• Highlighting alternative perspectives Dialectic
• Assisting other person to put their thoughts and feelings into words Interpretive
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A Dynamic Continuum
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• Avoiding intense emotions
• Rigid, stereotypical thinking
• Excessive significance given to subjective exeprience
• Hyper arousal
• Thinks explicitly about own and others’ mental states
• Understands own and others’ emotional states
• Empathic • Understand and repairs
relationship ruptures
• Frequent, unwarranted assumptions about the mental states of others
• Emotionally aroused, angry manner
• Overlays other’s minds with own traumatic memories
• Hyperkynetic
Mentalizing Distorted
Mentalizing Non-
Mentalizing
Anxious activation of attachment behaviours impairs capacity to mentalize
Attachment-trauma – a context dependent failure of mentalizing
Mentalizing Treatments
Designed to correct underlying impairments in mentalizing by adopting a non-interpretive, “not-knowing,” inquisitive stance
Intended to facilitate the accurate recognition and acceptance of one’s own and others’ mental states (including the therapist’s)
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What is Therapeutic?
1. Children with attachment difficulties need something they don’t want Therapeutic work must provide gentle
challenge through our own interactional style
This needs to provide “security inducing” nurturance or it is likely to disorganize insecure attachment
2. The objective is to develop more trusting relationships
3. We must also provide a controllable interpersonal world
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The Mind of the Caregiver
Children change first in caregivers’ minds
Adult mentalizing of the child’s actions allows them to experience being the subject of coherent, reliable and rational thinking
Mentalizing provides a relational context in which it is safe to explore thinking that does not over-activate the attachment system
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The “Push-Pull Trap”
Therapeutic work is based on building a relationship
But close relationship is experienced as both soothing and fear inducing (“I hate you, don’t leave me!”)
However, without activation of the attachment system, the child cannot develop the capacity to function in interpersonal relationships
Mentalizing may resolve this “push-pull trap” through mindful regulation of intimacy
It also seems that young people “catch up” this capacity if later, secondary attachment figures mentalize accurately and explicitly
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Mentalizing milieu
Commitment to each child’s future by paying attention to our minds
Provides a professional version of human understanding (perhaps something close to love) Caring
Sharing
Milieu is rooted in understanding attachment and trauma
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Outcomes RCT for BPD in adolescents (Rossouw and Fonagy, 2012) Good research with foster carers in approaches that are
implicitly “mentalizing” (e.g. Dozier) No empirical data for LACYP – yet Young people report feeling safe, respected, listened to
and helped Staff report a sense of purpose (80% retention) Placement stability (2 – 4 years) Improved educational attainment Better physical health – inc. reduction in self-harm Greater mental well-being (seem happier) Less exploitation and abuse (inc. missing from care) Less involvement in crime and substance abuse Staff observed
Improved flexible thinking Greater capacity for empathy Greater self insight Improved insight into others
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Mentalizing capacity
Mentalizing stance – recognizes interpersonal problem connected to low mentalizing
Inaccurate mentalizing - assumes that the other has same capacity as they do, and acts accordingly
Poor Mentalizing capacity- difficulty in understanding the expectations and motivations of others
ChrisTaylorSolutions.org.uk Watch out for these during this activity…….
Let’s Try It…
1. What were you thinking as the situation unfolded? How did you feel?
2. What do you think the waitress might have thought Robert was thinking?
3. How might this have left her feeling? 4. What do you think Robert was thinking about
the waitress? 5. What do you think Robert was thinking when
he became angry? 6. Why do you think Robert’s and the waitress’s
thought / feelings were different (or similar)? 7. Can you comment on differences or
similarities?
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Some References Allen. J. G., (2006) Mentalizing in practice, in J. G Allen and P. Fonagy, (Eds) (2006). Handbook of Mentalization-Based Treatment. Chichester: John Wiley and Sons. Bateman, A., and Fonagy, P. (2010). Mentalization based treatment for borderline personality disorder. World Psychiatry, 9, 11-15. Blakemore, S-J., (2008). The social brain in adolescence, Nature Reviews Neuroscience, 9, 267-277. Clough, R. Bullock, R. & Ward, A. (2006) What Works in Residential Child Care. London: NCERCC & National Children’s Bureau. Chungai, H. T. (1999). Metabolic imaging: A window on brain development and plasticity. Neuroscientist, 5, 29-40. Fonagy, P. (1989). On tolerating mental states: theory of mind in borderline patients. Bulletin of the Anna Freud Centre, 12, 91-115. Main, M. and Soloman, J. (1986). Discovery of an insecure/disorganized attachment pattern. In T. B. Brazelton, and M. W. Yogman (Eds) Affective Development in Infancy, Norwood, N. J.: Ablex. Rossouw, T., Kovacova, K., Stathopoulou, E., Wright, C., and Vrouva, I. (in press) http://www.deviersprong.nl/files/Viersprong_Academy/Maintaining_a_mentalizing_focus_in_the_storms_of_high_risk-trauma-hallucinations_and_admidst_a_busy_inpatient_unit.pdf. Sadler, L., Slade, A., & Mayes, L. (2006). Minding the baby: a mentalization-based parenting program. In J. G. Allen, & P. Fonagy (Eds.), Handbook of mentalization-based treatment (pp. 201-222). Chichester: John Wiley & Sons. Schechter, D., & Willheim, E. (2009). When parenting becomes unthinkable: Intervening with traumatized parents and their toddlers. Journal of the American Academy of Child & Adolescent Psychiatry, 48(3), 249-253. Suchman, N., DeCoste, C., Castiglioni, N., Legow, N., & Mayes, L. (2008). The Mothers and toddlers program: Preliminary findings from an attachment-based parenting intervention for substance-abusing mothers. Psychoanalytic Psychology, 25(3), 499-517. Søderstrøm, K., & Skårderud, F. (2009). Mentalization-based treatment in families with parental substance use disorder: Theoretical framework. Nordic Psychology, 61(3), 47-65. Taylor, C. (2012), Emphatic Care for Children with Disorganized Attachments A Model for Mentalizing, Attachment and Trauma-Informed Care. Jessica Kingsley Publishers: London and New York
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