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Attachment behaviour allows the infant to draw others towards them at moments of need or distress (Fonagy et al., 1995).

A biological system for coping with threat, not active when no threat is perceived

WHAT IS ATTACHMENT?

a reasonably firm expectation of feeling protected and safe, which in turn allows them to explore their world more confidently.

WHAT ARE WE AIMING FOR?

WHAT CAN GO WRONG? PART 1 OF 3

Degree of responsiveness to separation

Avoidant Resistant

Secure

Organised

Vs

Disorganised

WHAT CAN GO WRONG? PART 2 OF 3

Reactive Attachment Disorder

Lack of attachment behaviours

Extreme maltreatment

Rare

Disinhibited Social Engagement Disorder

Lack of inhibition

Decreasing link to maltreatment

Neurodevelopmental, rare

WHAT CAN GO WRONG? PART 3 OF 3

Secure organised attachment

Insecure organised attachment

Disorganised Attachment

Attachment Disorder

CLASSIFICATIONS AND TERMINOLOGY

Attachment Difficulties

Attachment problems

No place for ‘disordered attachment’

Abnormal caregiving

Disturbed attachment

Negative internal working models

Poor outcomes

Questions:What kind of abnormal caregiving?Can patterns be altered?Does altering patterns/ models result in better outcomes?

CLINICAL SIGNIFICANCE- THE NARRATIVE

ABNORMAL CAREGIVING AND ATTACHMENT PATTERNLack of sensitivity

Insecure attachment

Abuse/ neglect

Disorganised attachment

Extreme abuse

RAD

Good evidence for link in infancy, poor for significance

Good evidence for link, moderate for significance

Good evidence for link,Good for significance

Insecure and disorganised lumped together

Video feedback effective but not available

Link to broader function unclear

THERAPEUTIC EFFECTIVENESS

LifespanBehaviour

Responses

Narratives

Non-threat“Attachment theory also

describes the ways in which

individuals handle their most

intimate relationships with

their parents, children and life-

partners”

ATTACHMENT CREEP

Disorganised attachment as an indicator of impact of abuse

Attachment security as a part of a formulation with other factors

Recognising RAD and DSED and referring

PERSONAL VIEW- WHAT IS IMPORTANT

Inappropriate

therapies

WHAT’S THE HARM?

Blame

Shame

Denial

Disengagement

WHAT’S THE HARM?

Narrow vision

Assumption of harmful parenting

Confirmation bias

WHAT’S THE HARM?

Missed diagnosis

ADHD SpLD Anxiety PTSD Depression Ongoing abuse

WHAT’S THE HARM?

Therapeutic nihilism?

WHAT’S THE HARM?

SUMMARY

• An important process not a unifying theory

• Evidence base clearest in infancy for increasing sensitivity, but dissipates rapidly outside this

• Insecure and disorganised attachment quite distinct

• Can lead professionals down blind alleys.

Question what is meant by “attachment X”

Ask what therapeutic intervention this leads to.

Resist closing down of other avenues

MY PERSONAL ADVICE

Critical thinking is important!!

FINAL MESSAGE

A small plug

PMHA winter meeting

28-29 January 2016

Highgate house

LAC, impact of maternal abuse, diagnostic controversies, Public Mental Health

Pmha-uk.org for details