Attachment in Mental Health and Therapy

Applying Attachment TheoryThe FOUR ESSENTIAL DIMENSIONS1) SELF - in - relation - to – OTHER

(Symptoms are seen as imbedded in the “Attachment System”)

2) The Primacy of Emotions3) Promoting Metacognition4) Provision of a Secure Base and Safe Haven

CAROLCarol 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 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.

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.

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.

• 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

INTERNAL WORKING MODELS

SELF AND OTHER QUADRANT

Negative feelings and thoughts about self >>>>>

Negative feelings and thoughts about

other >>>>>

SECURE

PREOCCUPIED

DISMISSIVE

FEARFUL

Attachment Style Questions (Iemma, Target, Fonagy 2011)

a) 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)

b) 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)

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)

The Problem as part of the Client’s Attachment System

SELF-OTHER Constructs of the Internal Working

Model

The Problem or Symptom

Actual Self and Other

Describing the Self – Other Representation that is meaningfully connected to the presenting

symptoms/difficulties

1) Ask yourself: How does the client experience themselves in relation to others?

2) Identify who does what to whom and the associated affect.

3) How is this internalised self-other representation manifest in their outer life?

4) How might their representations of self/others influence and be influenced by current relationships?

5) How does this internalized self-other representation manifest themselves in relation to you, the therapist?

Interpersonal-Affective Focus (IPAF)

Defensive Function of this interpersonal configuration

Affect

Object (Other) Representation

Self-Representation

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 themselveschanged?

CAROL’s Interpersonal-Affective Focus (IPAF)

Defensive Function of this interpersonal configuration

Affect

Object (Other) Representation

Self-Representation

CAROL’s Interpersonal-Affective Focus (IPAF)

Defensive Function of this interpersonal configuration

Defends against awareness of her own

wish to punish the other and her responsibility for

making unreasonable demands on others

AffectPANIC –

ANGER/RAGE

Object (Other) Representation

REJECTING

Self-RepresentationNEEDY,

DEMANDING

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

Mentalized Affectivity

• Elliot Jurist’s 2005 3 part process1) Identifying Affects - naming

- distinguishing2) Processing Affects - modulating

- refining3) Expressing Affects - outward expression

- inward expression

The80-20

Rule

Fonagy, Iemma, Target 2011 Focus on Emotions

a) Focus on how some affects need to be kept in check by defences

b) Focus on how some affects function as defences (=EFT )

c) Focus on how emotions are managed or discharged

Fonagy, Iemma, Target 2011 Aims of Work on Emotions

1) Identify what the client feels, encouraging them to stay with a current feeling as it emerges in the session

2) Help them to communicate their feelings more effectively.

3) Build a capacity for the client to connect their emotions to the IPAF

Interpersonal-Affective Focus (IPAF)

Defensive Function of this interpersonal configuration

Affect

Object (Other) Representation

Self-Representation

Emotionally Focussed Therapy

1) Primary Emotions2) Secondary Emotions3) Instrumental Emotions

Heightening and Softening Interventions

Sue Johnson VIDEO – Heightening and Softening

EFT RISSSC Interventions with Emotions

R Repeat key words or phrasesI Images that evoke emotionsS Simple, concise phrases are powerfulS Soft, soothing tone to create safetyS Slow the pace to deepen emotional

experienceC Client’s phrases are used

Common Attachment Fears Common Attachment Needs

being rejected acceptance

being abandoned Closeness

Not measuring up, being a failure understanding

Not being accepted or valued To feel important

Being unlovable To feel loved

Being over-controlled Boundaries, differentiation

Being burdened by other’s needs

Interlocking Vulnerabilities

Explicit/Defensive Behaviour

Underlying Vulnerabilities

CAROL OTHER

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

Failures in Mentalization (Fonagy et.al 2008)

Psychic Equivalence ModeWorld=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 enoughauthentic feelings do not accompany thoughtscan make wild assumptions about mental states of others, “hypermentalizing” “destructively inaccurate mentalizing”

Teleological ModeMental states are comulsively acted outOnly actions and their tangible effects counteg. self harm, violence

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

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 mindWhen they are excessively focussed on others, invite them to focus on his or her own mind

Features of Good MentalizingAcknowledgement of Opaqueness

Absence of Paranoia

Contemplation and Reflection

Alternative Perspective Taking

Genuine Interest in others’ views

Open to discovering

Understanding and forgiveness of others

Perception of own mental functioning

Developmental apprecistion

Realistic Scepticism (not taking others on face value)

Acknowledgement of preconscious functioning

Understanding impact of affect

Coherent self presentation and cohesive self-narrative

Jon Allen: Some people need to feel more about their

thinking.

Some people need to think more about their feelings.

• What interventions come to mind with respect to Carol?

• Bateman - you tube role play

• http://www.youtube.com/watch?v=ilpD1ZtdbFs

Scenario - CarolCarol 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.

4) Providing a Secure Base and Safe Haven

Mentalizing capacity can only be fostered in the context of a secure attachment environment

• 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, 1/3rd reattuning

Optimal Conditions for Secure Attachment – CRADLE TO GRAVE

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.

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)

Hermeneutic Circle (Dilthey)EXAMINATION OF THE PARTS

3rd Pre-

understanding

2nd Pre-

understanding

1st Pre-

understanding

1st Understanding

2nd Understanding

3rd Understanding

DEEPER UNDERSTANDINGS

COMPARISON WITH THE WHOLE

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.” (Fonagy et,al 2010)

• Not Knowing (Harlene Anderson) • Tentative Interpretation

Kohut

“….transmuting internalization of the self-object functioning of the therapist”

IDEALIZINGMIRRORINGTWINSHIP

REPAIRING SCHISMS Six 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

“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)

Carol

What are the potential issues for the client therapist relationship?