"Earning" security of attachment: How is this possible through psychotherapy?
Tirril Harris
0207-848-0025 [email protected] www.ian-attachment.org.uk
Using Theory to Inform Practice
1. Outlining Attachment Theory, with particular attention to:- a) Different ways of typifying the defences i) Focussing on which relationships in which time period? ii) Contrasting attitudes and behaviour iii) Identifying key sub-categories b) If we are to modify them we need to know the origins of these defences
2. Looking at any other theories about health and attachment relationships which might be relevant.
3. Exploring how 1) and 2) might inform our practice.
4. Putting flesh on 3) by following some case histories.
The perspective of attachment theory
Attachment theory posits a special goal-corrected behavioural system promoting proximity-seeking to a key caregiver to achieve affect regulation. This is over and above the instincts for survival (fight or flight) and for reproduction.
Darwinian theory posits the survival of the fittest – i.e. Those who obtain most proximity to their caregiver(s) will survive to pass on their traits to the next generation.
John Bowlby emphasised the importance of the outer world alongside the inner world i.e. Life events deserve attention in explaining emotional state. Attachment theory and survival
Heightened arousal prevents death at the hands of predators via fight or flight
Protection by caregivers permits survival without the exhaustion caused by chronic hyper-arousal of the fight/flight systems
Sensitive/responsive caregiving also aids affect regulation
Affect regulation may also promote emotion recognition and thus self-reflection
Without such caregiving the child will develop defences against the frustration of his basic (attachment) needs
The development of these defences is an unconscious process
Such defences are often called attachment styles Three approaches to assessing relational style
1. Observing children as children relating to others (Mary Ainsworth. Pat Crittenden)
2. Interviewing adults about how they have processed their childhood relationships, specifically with caretakers (Mary Main)
3. Interviewing/observing adults about how they are relating as adults (John Bowlby; also Colin Parkes, Kim Bartholomew, Cindy Hazan, Phil Shaver and others) Measures of security of attachment transcending self reporting questionnaires and determining style of affect regulation
CHILDREN ADULTS Strange Situation Test (SST) Adult Attachment Interview (AAI) (Ainsworth, Blehar, Waters and Wall,1978) George, Kaplan and Main, manual1985
Avoidant (A) Dismissive (Ds) Secure (B) Secure, autonomous (F) Anxious ambivalent/resistant (C) Preoccupied/Enmeshed (E) Disorganised (D) Cannot Classify (CC) Elaboration A1-8. B1=5, C1-9, AC in
Crittenden’s Dynamic Maturational Model (1997)
ADULTS Bowlby, Volume III of the trilogy, 1980 Internal Working Models of relationships Avoidant, Secure, Anxious ambivalent, Compulsive Caregiver Insecure Attachment ANXIOUS/AMBIVALENT/PREOCCUPIED Background: Inconsistent responsiveness of caregivers in early life. Lack of confidence in reliable responsiveness of others. Felt security attempted by devoting mental energy and behavioural effort to keeping others close by and engaged. High rate of relationship ‘dissolution’. Overly intimate self-disclosure; obsessive preoccupation with partner’s responsiveness; falling in love easily; jealousy. Subject to fear, anxiety and loneliness (even when in a relationship) AVOIDANT (DISMISSIVE OR FEARFUL) Background – consistent unresponsiveness of caregivers in early life. Avoidance of intimate social contact especially in stressful circumstances. Compensatory engagement in non-social activities e.g. use work to avoid social interaction. Lack of closeness in relationships. Judged by peers to be hostile. High rate of ‘dissolution’ of relationships. Avoidance of self-disclosure. Discomfort at others’ disclosure. Model of Attachment and the Self Adults Relating as Adults Following Bartholomew (1991) & Parkes (1984)
POSITIVE VIEW OF SELF NEGATIVE VIEW OF SELF
POSITIVE VIEW PREOCCUPIED/ SECURE OF OTHER ENMESHED
Comfort with closeness Overdependence Trust Desire for approval Healthy dependence Preoccupation with continuation of relationships
NEGATIVE VIEW OF OTHER DISMISSIVE FEARFUL
Avoidance of intimacy Lack of trust Lack of trust Interpersonal anxiety Valuing of independence Desire for intimacy Compulsive self-reliance Aloneness Dimensions of Attachment
HYPER- Enmeshed Fearful ACTIVATION
ANXIETY
Secure Withdrawn
Dismissive
DEACTIVATION AVOIDANCE Origins of the Attachment Style interview (ASI) Developed by the Team of my Bedford Square Colleagues Professor George Brown, Professor Antonia Bifulco, Professor Tom Craig, Patricia Moran
• Earlier we had used measures of helplessness and hostility in relationships to try to approximate John Bowlby's categorisation of attachment styles of adults with adults in volume III of his trilogy (1980) see Harris & Bifulco, 1991.
• Following both Mary Main's and Kim Bartholomew's perspectives we developed The ASI (Attachment Style Interview) Attachment Style Interview (ASI): A Semi-structured interview to assess How Adults relate as Adults BEDFORD SQUARE MEASURE Antonia T. Bifulco, Patricia Moran, Bronwen Ball, Odette Bernazzani, George W. Brown and Tirril Harris (Bifulco et al. 2002)
INDICATORS OF ATTACHMENT STYLE Mistrust of others In addition Coherence of Account is rated Attitudinal constraints concerning confiding. on a 4-pt scale Self-reliance Inability to tolerate separation Fear of intimacy Fear of sexual intimacy Desire for engagement Anger in relationships Ability to make and enjoy relationships
NON-STANDARD (INSECURE) ATTACHMENT Take the most pervasive attachment style e.g. if standard in all except romantic relationship then reflect as standard in overall rating. However, a secondary non-standard rating can be made where more than one style figures 0. Standard 1. Markedly preoccupied/enmeshed 5. Markedly dismissive 2. Moderately preoccupied/enmeshed 6.Moderately dismissive 3. Markedly fearful a) of rejection, b) of engulfment, c) of both 7.Withdrawn (but not 3-6) 4. Moderately fearful, a) of rejection, b) of engulfment, c) of both Gender and Attachment Style among brother- sister pairs in South London in 1996-8
GENDER
Male Female TOTAL
Type of Attachment Style % % %
Dismissive/avoidant 29 15 (14/94) 22 (39/179) (25/85) Fearful avoidant or 9 (8/85) 16 (15/94) 13 (23/179) enmeshed Standard/secure 61 69 (65/94) 65 (117/179) (52/85) Chi square = 6.24, 2df, p<.05 Pathare & Craig, 1999 Model of Psychological Development and Psychotherapy
OUTER WORLD Nature of Psychotherapy Change in supportive Adult Working SECURE BASE behaviour of others
Care-giver’s responsiveness Interpersonal Alliance Relationships TRANSFERENCETRANSFERENCE EXPLORATIONSEXPLORATIONS
Changed IWMs WORKING Internal Working Models IWMs THROUGH Goal-corrected behaviour Attachment Style Systems to meet basic needs Internal object Psychical representation Persons’ Relating to other (PROQ) Self-schemata Reciprocal role procedure Procedural sequence object Changed relations model Mental Personal construct system State INNER WORLD Core-conflictual relationship theme CHILDHOOD ADULTHOOD Dashed lines represent impact of inner world on outer world Continuous lines represent impact of outer world on inner world The importance of attending to the contribution of the external world
1. Early Caregiver's Responsiveness: sensitive or abusive/neglectful?
See Ainsworth maternal sensitivity scales focusing on sensitivity to infant signals:
Co-operation vs. interference with ongoing behavior Psychological and physical availability, Acceptance vs. rejection of infant's needs
2. Severe Life Events, eg death of attachment figure, emigration of key person: frequent or rare?
3. Adult social network responsiveness: emotionally supportive? Depression and provoking agents (life events etc) Camberwell Study 1978
Provoking Agent Provoking Agent Total Yes No
Depression yes 33 4 37
Depression No 131 251 382
Total 164 255 419 ORIGINAL CAMBERWELL INTIMACY QUESTION (1968)
If you had a problem of some sort, who would be the first person you would want to discuss it with? Percentage of Women in Camberwell who Experienced Onset of Caseness in Year by Whether they have a Severe Event or Major Difficulty (Provoking agent) and Intimacy Context. (Chronic cases excluded)
A= living in same household as confidant B= seeing confidant at least weekly C= seeing confidant but less than weekly D= no confidant at all
Intimacy Intimacy Intimacy
A high % B % C or D low % Provoking agent Yes 10 (9/88) 26 (12/47) 41 (12/29) Provoking agent No 1 (2/193) 3 (1/39) 4 (1/23)
PROVOKING AGENT (Severe Life Event/ Specific Generalised Major Difficulty) hopelessness hopelessness
VULNERABILITY FACTOR Low self-esteem DEPRESSION helplessness 1) Lack of Intimacy 2) Early Loss of Mother 3) 3 Plus Children at Home 4) Lack of Employment
SPECULATIVE MODEL ARISING FROM CAMBERWELL SURVEY 1978
Factors shown in caps were measured, those in lower case are speculative intervening variables REVISED QUESTIONS ABOUT INTIMATE SUPPORT (1980 - )
CONFIDING AND Do you confide in ………………….? AREAS OF NON- Can you tell me what sort of things you do confide in her/him about? CONFIDING (PROBE: About things that worry or upset you? Do you just touch on it or did you go into detail?)
What about personal things? Do you talk to them about things like that?
What about money matters? Sex? Pregnancy?
(PROBE: Or if there was trouble between you and your husband? Say a serious argument? Or things that
bother you about your relatives?)
Or, anything that might make her/him think badly of you? Such as?
Are there any things that you would not talk to her/him about? Why/why not?
ACTIVE Do they ever help you out? EMOTIONAL SUPPORT (GET DETAILS OF THE LAST TIME)
Could you ask them for help if you needed it? (e.g. would help with shopping if you were ill, babysitting).
Do you think …………. worries about you? (PROBE: If you are not feeling well? Have problems? How do they show it?)
AREAS OF NON- Are there particular things that you think he/she would be less supportive about? SUPPORT Does he/she ever say anything tactless? Definition of ‘Crisis Support’ (Bedford Square Measure)
1. Marked/moderate confiding about crisis, and 2. Marked/moderate emotional support with it, and 3. lack of any negative response. Examples of how there can be Negative Responses despite other Supportive Behaviour
Woman reports her pregnancy with 4th child to mother who then accompanies her to all medical check ups and plans baby sitting for the future. BUT mothers first reaction to news of this pregnancy had been “how could you have let this happen?”
Similarly the same women's sister had offered her all sorts of baby clothes and equipment for the new baby and talked about sharing child minding, but always took the line “ you have only yourself to blame”. Do any of us therapists ever get close to doing this”
Another woman's husband tried to offer her help about their financial problems but would then, without comment, that same evening, go out and drink away their money in the pub
Another husband apologised for having an extra-marital affair, saying he really loved her (the wife) but was like a child who couldn't stop having sweeties, but he continued for months to go out and visit his mistress despite having said that.
Characteristics of Emotional Support Legend: S = Subject or Client 0 = Other person/psychotherapist Reasons for S not confiding more Conflict of loyalties – nature of event Expects criticism from O O considered incapable of recognising problem O likely to deny problem as O is its source O likely to be unreceptive, as it co-victim S wishes to protect O S wishes to protect herself from losing face S wishes to protect herself from thinking about the crisis O is too far away S does not consider the crisis serious enough to merit confiding For some unclear reason S hardly ever confides in O O indiscrete – repeats confidences to others S has so many others she can confide in Expects interference from O, although not critical Unclear why S did not confide at this point – says thing like ‘too busy; etc. S realises O is incapable of helping her (not 3) Characteristics of Emotional Support Legend: S = Subject or Client 0 = Other person/psychotherapist Reasons for Other's provision of inadequate emotional support
Conflict of loyalties – O reacts disloyally O critical of S O minimises problem – too thick skinned to register it O minimises problem –and focuses on own problems O denies there is a problem – is partly (or wholly) its source O tries to avoid problem as is co-victim O is too far away O in all kindness tries to distract S, but too hurriedly O repeats confidences to others O is too vulnerable, gets in too much of a state O is in so much of a hurry to get S to take action that she doesn’t leave space for the required emotional support. O is sympathetic really, but external circumstances (O’s own preoccupying problems, lack of money, mean he/she cannot give time enough for S.) Metaphors for thinking about supportive relationships and onset of depression
• THE SANDCASTLE (of wellbeing, which like a castle, takes only one minute to break down into depression, and a long time to build up again)
• THE FIRE ENGINE (support which only arrives in an emergency and is rather noisy)
• THE MILK VAN (quiet, daily, delivery of a nourishing product) Operationalising measures of caregiving in childhood
• CECA (CHILDHOOD EXPERIENCE of CARE AND ABUSE) (Bedford Square Measure: Bifulco, Brown & Harris, 1994) Maltreatment (Childhood adversity) Neglect Physical Abuse Psychological Abuse Sexual Abuse Rejection Antipathy from parent Favouritism Scapegoating Role reversal (or parentification) Other Discipline Supervision Discord/tension/ violence between parent figures Loss of parent figure through death/long-term separation Bullying from non-parent figures Brown-Harris Psychosocial Model of Onset Of Depression
Childhood neglect SEVERE LIFE EVENTS* abuse SEVERE DIFFICULTIES
insecure attachment style LACK OF CRISIS SUPPORT DEPRESSION
low self esteem poor coping
* Severe means still markedly/moderately distressing after 2 weeks Moving towards studying remission rather than onset of depression
We required
Elaboration of Measure of Fresh Start Events ( as it were positive events which were the opposite of Severe Humiliating/Loss events) Definition of Fresh Start Type Event Events focused on the subject which give hope with regard to a situation that has involved an ongoing marked or moderate difficulty (leds) or a state of deprivation (sess). Relief or Difficulty Reduction Occasionally difficulties are reduced in severity without such an event – often these are interpersonal difficulties. Starting Treatment for Depression Although this does represent an experience of a new beginning, for methodological reasons this has been kept separate and so is not included in the definition of a ‘fresh start’. Recovery or improvement from Chronic Depression in terms of initial difficulty score, the experience of a fresh start event or a Difficulty Reduction, and Social Support
Good support Good Support Total YES No
Fresh start experience 85% (11/13) 43% (6/14) 63% (17/27) YES
Fresh start experience 57% (8/14) 25% (2/8) 45% (10/22) NO
Total 70% (19/27) 36% (8/22) 55% (27/49) Brown-Harris Psychosocial Model of Remission from Depression
Absence of childhood Absence of severe Neglect abuse Interpersonal difficulty at onset
FRESH START EVENT REMISSION
HIGH ONGOING CRISIS SUPPORT
A fresh start is an event which gives hope about a situation that has involved an ongoing marked or moderate difficulty or state of deprivation Earned Security
“Research suggests that adults who have developed a coherent perspective on their negative, early attachment relationships (i.e. earned secures) do not re-enact poor parenting practices with their own children.”
Phelps, Belsky & Crnic 1998, Developmental Psychopathology, 10, 21-38 Transference Interpretations
“Sometimes transference interpretations increase the space a patient needs for growth, sometimes they reduce it. It depends on that patient at that time.”
Page 168 in Josephine Klein, (1995) Doubts and Certainties in the Practice of Psychotherapy, London: Karnac Books. Differing Therapeutic Tasks: Story Breaking Versus Story Making
“If the task with avoidant patients is to break open the semi-clichéd narratives they bring to therapy, with ambivalent patients it s necessary to introduce punctuation and shape into their stories – a making rather than a breaking function.”
Page 169 in Holmes, J. (2000) Attachment Theory and Psychoanalysis: A Rapprochement. British Journal of Psychotherapy, 17, 157-172.
Having a more integrative model… could diminish the risk of making interventions that, being pertinent for a given subtype, could become inefficient, or even reinforce the pathology, when applied to a different one. Just as in medicine where even very useful medicines have clear cases in which they are contra-indicated, perhaps psychoanalytic interventions could also be thought of as indicated, or contra-indicated, and not as universally applicable.
(Bleichmar, 1996) Main tasks in Psychotherapy
Where Id was there Ego shall be
Promote insight through offering interpretation - cognitive emphasis
Provide a corrective emotional experience – more affective emphasis including facilitating “working through” previous painful experiences
Disconfirm the insecure patient's previous “Internal Working Models of Relationships” by providing a secure base via sensitive responsiveness Therapy tasks
Overall Task: to Disconfirm the insecure patient's previous “Internal Working Models of Relationships”
Phases 1. Building the working Alliance - with sensitive responsiveness 2. Ruptures and repairs to the alliance 3. The classical Transference 4. The use of other aspects of transference 5. Issues of countertransference 6. Outer world and social context ?fresh starts? Facilitate building an emotionally supportive network ATTACHMENT STYLE NAME OF PATIENT (Capitals = ASI and some AAI, DISCUSSED Lower case= Strange Situation Test and Bowlby’s own terms)
PREOCCUPIED/ PENNY ENMESHED (also AAI) (Anxious/Ambivalent/Resistant)
DISMISSIVE (also AAI) DEREK (with secure (Avoidant/ Compulsive/Self-reliant) colleague STEPHEN)
FEARFUL (OF REJECTION) FIONA, REHJAN (Avoidant)
FEARFUL (OF ENGULFMENT) EUGENE (Avoidant)
WITHDRAWN WILLIAM (Avoidant)
STANDARD/ SECURE (also AAI) SANDRA
COMBINED CLASSIFICATION =CC CLAIRE-CELINE (CC= CANNOT CLASSIFY in AAI, ?Disorganised) Using Attachment Classifications to build the Working Alliance
ATTACHMENT STYLE RELEVANT ISSUES FOR CREATING A SUPPORTIVE ALLIANCE AND TYPE OF PRIOR CAREGIVER (By disconfirming the internal working models of prior relationships) Issue: After an initial problem in talking at all, client may develop habit of FEARFUL (OF REJECTION) speaking a lot (to be obedient and thus avoid rejection), but not about the Caregiver consistently important things of which he/she may be ashamed and which he/she rejecting/unresponsive therefore fears will earn him/her rejection. to needs Focus: Convey that therapy is non-judgemental: talking truthfully about shameful parts of the self will not call forth rejection or disapproval.
FEARFUL (OF ENGULFMENT) Issue: Client may be able to speak freely but may experience therapist’s comments, especially transference interpretations, as controlling or intrusive Caregiver imposing control/ and so be unwilling to listen/hear. May ward off therapist with a flood of talk. Consistently unresponsive Focus: Pace interpretations gradually until client has come to feel there is to needs room for him/her to be himself/herself.
WITHDRAWN Issue: Client may not have much to say, not having had as much practice in Caregiver consistently interpersonal communication as others. unresponsive/ never taught Focus: May need encouragement, even gentle ‘instruction by example’, the value of relating before can free associate openly. Using Attachment Classifications to build the Working Alliance
Issue: Client may ‘dismiss’ what therapy has to offer, denying the truth of valid DISMISSIVE interpretations. Caregiver consistently Focus: Pace interpretations until client has begun to feel the value of ‘having to’ unresponsive in any, or all, of confide, occasionally interpreting the behaviour of others in his/her network as a ways outlined above way of introducing the genuine value of attachments; remain responsive despite client’s negativity Issue: Client may get stuck because the boundaries of the therapeutic frame reawaken his/her ambivalence: he/she may try to manipulate some sort of PREOCCUPIED/ENMESHED change in boundaries. Caregiver inconsistently Focus: Initial flexibility may be important as it disconfirms the prior experience of responsive inconsistent responsiveness: only then may it be possible for the client to explore why he/she had such a need for change. Too rigid adherence to the frame may make such exploration impossible as the alliance still feels too unsafe
Issue: Usually none, but sometimes the artificial nature of the therapeutic dyad STANDARD/SECURE may discourage a client from using the therapy. Caregiver consistently Focus: Show that the secure internal working model can also be applied in responsive enough therapy despite constraints. Concluding Remarks The theme of this conference may strike many of you as sounding like interpersonal engineering, how can we fix people's attachment styles? And so you may draw back from engaging in such “tinkering”. Attachment security is only a mediator not a final outcome. In the end psychotherapists should be responding to what their clients request, and that is often merely something vague such as hoping to feel less miserable, anxious or angry. Therapy can often help without someone having to become fully secure in their attachment style.
They may become much happier as a result of the secure base provided by their therapy, while still insecure. Or they may become more coherent about why they do things, or more reflective about the motivation of others without fully “earning attachment-security”. In other words , they may become mildly rather than markedly dismissive, or mildly rather than moderately enmeshed, and feel much better about themselves, the world and their future. This is what really counts, so we should not berate ourselves if their attachment styles have not become fully secure.