Attachment and Metacognition : Converting Attachment Theory Into Attachment Practice

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Attachment and Metacognition: Converting Attachment Theory Into Attachment

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Attachment and Metacognition : Converting Attachment Theory Into Attachment Practice. Jodie was a 24 year old woman who was referred for counselling by her GP because of “depression, anxiety, possible panic attacks, and unresolved grief over her parents’ divorce”. - PowerPoint PPT Presentation

Transcript of Attachment and Metacognition : Converting Attachment Theory Into Attachment Practice

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Attachment and Metacognition: Converting Attachment Theory Into Attachment Practice1Jodie was a 24 year old woman who was referred for counselling by her GP because of depression, anxiety, possible panic attacks, and unresolved grief over her parents divorce.The divorce happened at a crucial time in Jodies adolescence. She was 16 and in year 11 at school. Her mother moved out of the home abruptly, began night-clubbing and making up for her lost youth. Jodies father became depressed and withdrawn. Her two older sisters had either moved out of home or were on their way to moving out. Jodie floundered at school and became quite depressed. After a period of time, Jodie started having what she called fits. She described how out of the blue her body would develop a tingling sensation and numbness, and she would find herself unable to move or talk. Various medical specialists were unable to find a physical cause for these episodes and alternative health practitioners were unhelpful.After high school, Jodie had a series of service-related jobs. At the time of the referral, Jodie had a new boyfriend who was quite seriously committed to her. She continued to have a fractious relationship with her family. Her mother kept up her exuberant lifestyle and her father moved on to a new marriage. Both seemed preoccupied by their new lives. When she had contact with them, Jodie felt pressured and used. For example, her mother kept a dubious tally of all her financial contributions to Jodies living and educational expenses since the break up and often used this as a means of leveraging favours or money from Jodie. Jodie still lived in the family home, waiting for her parents to make a decision about selling it and settling property.

Share in PairsWhat stands out to you. What would you be wanting to find more information about.2INTERNAL WORKING MODELAn 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 blue-prints that determine how we perceive, edit, and interpret our relationship experiences. Because these blue-prints shape our response to others, they also shape the actual relationship dynamics, and so become self-reinforcing.

3EARNEDSECURITYMain, Sroufe the holy grail of attachment oriented psychotherapy- moving from a less secure and a more anxious IWM to a more secure and less anxious IWM4Correspondence between SS and AAI CategoriesStrange Situation Adult Attachment InventorySecure

Avoidant

Ambivalent

Disorganised

Autonomous/Free

Dismissing/Avoidant

Preoccupied/Enmeshed

Unresolved for loss or traumaSecure Attachment Style Autonomous/FreeComfortable in relationship settings. Readily contribute to interdependent relationships as a springboard for engaging in the wider world.Less distressed by interpersonal conflict. Able to engage in productive, task-oriented conflict.Less preoccupied with the need to elicit positive regard from others or the need to avoid closeness with others.Generally able to access attachment figures for connectivity, soothing and intimacyMetacognition Main 1991

Reflective Function (Fonagy and colleaugues 1997)

Mentalization

The term Meta-cognition was first championed in the attachment arena by Mary Main (1991) and refers to the ability to recursively reflect upon ones thoughts and feelings and view them as mental representations or constructs that are influenced by beliefs, biases, emotions and interpersonal context, and as subjectable to change. For Main, this ability is fostered by a secure attachment context and can be developed in therapy to improve mental health outcomes.

Reflective Functioning is an attempt to operationalize metacognition. Fonagy and colleagues, developed the Reflective-Functioning (RF) Scale used to assess the quality of meta-cognition in responses to AAI:- Negative RF > Lacking in RF > Questionable RF > Ordinary RF > Marked RF >Exceptional RFIs an instrument that has allowed research to study the interelationship of metacognition and other variables.7Mentalizing

The act of reflecting on ones own mental representations of self and other (and associated feelings); AND at the same time being able to reflect upon the other persons mental representations, feelings, and intentions. (benign intentions)

Moreover, it involves perceiving the connection between ones mental state and that of the other person.

INTENTIONAL STANCE

MindreadingTheory of MindMindfulnessMindsightMindreading: Focus is on others mental states and emphasis is on cognitions.

Theory of Mind: Focuses on early cognitive development. Capacity for Theory of Mind is developmental building block for Mentalization.

Mindfulness: Pushing the Pause Button. Focuses on the present and is not limited to mental states. Usually emphasis is on awareness detached fromemotional arousal CF Mentalization and mentalized affectivity.

Mindsight: Is very similar to mentalizing. Seigel talks about gaining the ability to construct more useful me maps, you maps, and we maps. Siegel emphasises developing greater awareness of ones internal physiological and mental state (me-map) and the neuro-chemical rewiring that results from mindfulness practice to then allow greater capacity to make you and we. The people9Facets of MentalizingFacetAspectContent of mental states

Level Of representations

Object

Time Frame

ScopeNeeds, desires, feelings, thoughts, hallucinations, intentions

Explicit (narrative) to implicit(intuitive)

Self Vs Other

Past,present, future

From narrow (eg. present mental state) to more broad (eg. autobiographical context)10ResearchRF and Mentalizing Capacity has a higher correlation with mental health outcomes than AAI categories (Fonagy et,al 2006)Mentalizing capacity of parent is more accurate than their AAI category in predicting security in their children (Slade)Secure attachment is conducive to childrens mentalizing capacity BUT contingent mentalizing responsiveness by parents is key (Meins et al. 2001)Inaccurate maternal mentalizing is associated with high levels of psychopathology (Sharp et,al 2007)Greater mentalizing ability in parents is associated with lower physiological arousal and greater emotion-regulation in their children (Gottman and colleagues, 1996)Parents who use disciplinary strategies that focus on mental states results in enhanced mentalizing capacity in their children (Sabbagh and Callanan 1998)Mentalization capacity in children correlates with ability to tolerate negative affect (Dunn and Brown 2001)

GOTTMAN AND COLLEAGUES : used the term meta emotion philosophy i.e. parents feelings and thoughts about their own and their childrens emotions, their responses to their childs emotions, and their reasoning about these responses (p245)11Features 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 othersPerception of own mental functioning

Developmental appreciation

Realistic Scepticism (not taking others on face value)

Acknowledgement of preconscious functioning

Understanding impact of affect

Coherent self presentation and cohesive self-narrativeFailures in Mentalization (Fonagy et.al 2008)Psychic Equivalence ModeWorld=Mind, ideas are too realconstructs are not distinguished from external reality that they represent eg. dreams, flashbacks, paranoid delusionsPretend Mode ideas are not real enoughauthentic feelings do not accompany thoughts Feelings and thoughts are role-playedcan make wild assumptions about mental states of others, hypermentalizing destructively inaccurate mentalizingTeleological ModeMental states are compulsively acted outOnly actions and their tangible effects counteg. self harm, violence13What constitutes an Attachment Perspective for enhancing Metacognition in Psychotherapy?All Psychotherapy approaches essentially grapple with this.

It is when the endeavour of enhancing metacognition is done along side the following considerations.

14Regarding symptoms as imbedded in the clients attachment system

Appreciating the primacy of emotions and their relationship with the clients attachment system.

A concern with providing a secure base context in and out of therapy.15The Problem as part of the Clients Attachment SystemDescribing the Self Other Representation that is meaningfully connected to the presenting symptoms/difficultiesAsk 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?The Primacy of EmotionsLe Doux (1996) emotions are free standing phenomena

Damasio (1994) emotions organise cognitions not visa versa

Schore emotions can be implicit and explicit, they can be consciously or unconsciously experienced- arousal and tolerance of emotional states is necessary to access pre-cognitive, implicit memories and to allow cognitive elaboration

Fonagy and colleagues emotions are intentional they have a purpose related to ones attachment systemUnlike Cognitive-Behavioural approaches , Attachment approaches have always afforded primacy to emotional experiences and have formulated these in terms of their relation to a persons attachment systems.In privileging emotional material, many attachment-oriented authors refer variously to the research of Le Doux, Panksepp and Damasio (Fonagy et al. 2004; Johnson 2009; Solomon 2009).

Le Doux (1996) found that emotions can be experienced and responded to in the absence of neocortical involvement, ; that they are phenomena in their own right and not mere by products of cognitive processes..

Damasio (1994) showed that emotions and body experiences actually organise cognitive reasoning, decision-making, and the experience of self-hood.

Schore (2009) stresses the implicit and unconscious nature of emotional experiences in and out of therapy; that emotions can be experienced and regulated without cognitive elaboration and without even outward expression. Schore argues that arousal and tolerance of emotional states is necessary to access pre-cognitive, implicit memories and to allow cognitive elaboration and meaning-making to occur in therapy.

Fonagy (at al. 2008) make the point that emotions are intentional, i.e. that they are about self and other and have a meaning and purpose that can be elicited in therapy.

183 goals of working with emotions1) to explore constructs of self and other which are seen as best accessed in the context of emotional arousal2) to promote opportunities for experiencing interpersonal affect regulation3) to promote the clients ability to self-regulate through re-appraisal of their affective experience.

Distinctions between attachment approaches can be drawn from how they emphasize each of these goals.

MBT deemphasises insight as a means to change but explicitly seeks to enhance the clients ability to cognitively reflect upon their emotional state and to consider more useful constructions of self and other. MBT also emphasizes the crucial role of the therapist in providing interpersonal affect regulation to facilitate this mentalizing enterprise.

Emotionally Focussed Therapy operates on the basis that secondary defensive emotions like anger must be accessed before softer primary emotional states such as grief and sadness can emerge. For example, Jodies nascent rage at her boyfriends belligerence can be seen as secondary reactive emotions sitting above a core attachment need to be recognized as a person with unique and valid needs of her own that are separate from her attachment figure.In EFT-C, unlike other attachment approaches, working the emotional seam is not done so much for the purpose of insight or for committing them to cognitive awareness, but rather to change the quality of interactions couples or family members have with each other. The goal is to experientially draw empathy and engagement from important others by expressing their needs in a less threatening or softer manner (Johnson,1988).

EFT-C uniquely offers a dogged pursuit of core vulnerabilities and a construction of these as expressions of attachment-related needs. Interpersonal affect regulation is promoted between couples rather than with therapist.

19Mentalized AffectivityElliot Jurists 2005 3 part processIdentifying Affects- naming- distinguishing2) Processing Affects - modulating- refining3) Expressing Affects- outward expression- inward expression

Distiguishing especially when more than one emotion is involved eg. Carol might need to distinguish between anger and despair at others not being available

Modulating altering the intensity and duration Modulating up or down - in therapy may choose to up-modulate an affect so client can learn to tolerate it and also reflect upon it

Refining reviewing meaning of affect, gaining a greater sense of complexity of the meaning eg. grief and loss process end of relationship, greater complexity of emotions and meaning of emotions equals greater resolution

Eg Carol might benefit from more clearly articulating her sadness when others are unavailable, to talk about how she feels she is not wantable to others and also powerless to get what she wants from others, how this reminds her of something that happened as a child - disarms the potency of the here and now experience and creates new meanings

80-20 RULE

Inward Expression Carol when angry and resentful of others, reconnecting with other feelings20Prompt responsiveness to distress, Non-Intrusiveness, Interactional Synchrony, WarmthMid-Range Tracking of Childs Affect (Beebe and Lachman 2002)Contingent and Marked MirroringContainment understand the cause of distress - do not join in their distress - recognise their intentional stance

Mirroring Meta-Cognitive CapacityIntersubjectivity Repeated cycles of attunement, misattunement, and reattunement (Schore 2008)REPAIR GOTTMAN and couples

Optimal Conditions for Secure Attachment CRADLE TO GRAVEMAKE THE POINT THAT THESE CONDITIONS APPLY TO 1) CHILD-PARENT ATTACHMENT, 2) ADULT ATTACHMENT RELATIONSHIPS, AND 3) THE THERAPEURIC RELATIONSHIP

2) Tracking between mother and infant should close but not perfect. Too low (unresponsive) then greater chance of avoidant attachment system, too vigilant then greater chance of resistant/ambivalent attachment system.

5) Fonagy et,al : secure attachment is a precondition for high meta-cognitive ability but is not enough. The child perceives in the caregivers stance an image of himself as mentalizing, desiring and believing. He sees that the caregiver represents him as an intentional being. It is this representation which is internalised to form the self (Fonagy 1996)

6) Intersubjectivity refers to the phenomenon whereby two people experiences themselves as being in the mind of the other. It is the context for the development of identity, the self, and agency or mastery. (OR LACK OF)

www.geofffitzgerald.com.au [email protected] 0432 075 088Jodie was a 24 year old woman who was referred for counselling by her GP because of depression, anxiety, possible panic attacks, and unresolved grief over her parents divorce.The divorce happened at a crucial time in Jodies adolescence. She was 16 and in year 11 at school. Her mother moved out of the home abruptly, began night-clubbing and making up for her lost youth. Jodies father became depressed and withdrawn. Her two older sisters had either moved out of home or were on their way to moving out. Jodie floundered at school and became quite depressed. After a period of time, Jodie started having what she called fits. She described how out of the blue her body would develop a tingling sensation and numbness, and she would find herself unable to move or talk. Various medical specialists were unable to find a physical cause for these episodes and alternative health practitioners were unhelpful.After high school, Jodie had a series of service-related jobs. At the time of the referral, Jodie had a new boyfriend who was quite seriously committed to her. She continued to have a fractious relationship with her family. Her mother kept up her exuberant lifestyle and her father moved on to a new marriage. Both seemed preoccupied by their new lives. When she had contact with them, Jodie felt pressured and used. For example, her mother kept a dubious tally of all her financial contributions to Jodies living and educational expenses since the break up and often used this as a means of leveraging favours or money from Jodie. Jodie still lived in the family home, waiting for her parents to make a decision about selling it and settling property.

In Small Groups What interventions would you be naturally beginning to think about with this case. _ How do you normally go about promoting meta-cognition?22Interventions that Enhance Mentalizing CapacityAn inquisitive, not knowing stanceExploring interactions and self-experiences from multiple perspectivesValidating their experience before offering alternate perspectivesLetting client know what you are thinking and inviting them to correct itTwo hands

Interventions that Enhance Mentalizing CapacityIdentify a break in mentalizingRewind to a moment before the breakExplore the current emotional context (client-therapist dynamic?)Make contrary movesWhen 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

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

Some people need to think more about their feelings.INTERLOCKING VULNERABILITIES

Surface Behaviour & Non-VerbalsUnderlying Feelings & VulnerabilitiesSurface Behaviour & Non-VerbalsUnderlying Feelings & VulnerabilitiesRodney (Jodies boyfiend) is from India of Punjabi origin. One Friday afternoon he came home from a long days work hoping to see Jodie and spend the evening with her. He home to find Jodie dressed up to go to the Pub and meet a girlfriend.Rodney started criticising her tight jeans and make-up.Jodie tried to reassure him that she was just have a drink or two with her friend and then would be home after that.Rodney began sulking and cut-off from her.Jodie took herself off to the bathroom and locked herself in. She became numb in her body and unable to speak. Rodney came to speak to her, asking her to let him in. Jodie found herself unable to move or to speak to him. Rodney alternated between calling Jodie childish and pleading with her not to be upset with him.Some Old Time Family Therapy FavouritesCircular Questions Triadic QuestionsOther-Oriented QuestionsMore or Less Questions Imagined-Other QuestionsReflexive QuestionsDifference QuestionsCircular Questions Who else is contributing to this? How do others help or hinderwith this situation? How is this situation seen by others? When Debbie does that, is the problem better or worse? What are the possible benefits for the problem being there? How might it suit Bruce?Triadic QuestionsIs Mum closer to dad now or more distant? Does Bob seemmore open to what John has to say or less? What does John do when Mary does that?Other-Oriented QuestionsWhat do you imagine goes on for Tim when he says that? Has Tim alwaystended to react like that? What would that be like for him?More or Less Questions Who is the most affected by this? Who is the least affected by this? Who is the most motivated? Rank them in order. Who do you think isthe strongest person? How do you account for that?Imagined-Other QuestionsHow do you imagine Jill would answer that? When you do that, what doesSteve experience? How would Sally be feeling right now as you tell me this?Reflexive QuestionsIf you were more able to do that, what difference would that make to your relationship? If you had said that what difference might that have made? Difference Questions Who has a different opinion? Do you feel exactly the same as Lucy? Do you feel slightly different to Lucy? How do you account for that?

28TISSUE BOX Jodie Mentalized Affectivity 1During one session, Jodie related her annoyance at her family members not accepting her new boyfriend because of his Indian ethnicity. As she spoke about her sisters racism, Jodie went quiet and looked down at the floor. She moved her hands in short, agitated movements.Therapist: What are you experiencing right now, Jodie? Jodie:(After a long pause). I dont know. I guess I feel really frustrated. How could they talk about Rodney like that?Therapist:What feeling do you think you are having as we talk about this? (mentalizing affect)Jodie:Im not sure. Pissed off maybe?Therapist: Would it be fair to say that you are feeling anger?(Jurists, 2005, identifying)Jodie: Yeah. Yes thats right. Im really pissed off!!Therapist:(Wanting to help Jodie to explore and articulate this feeling further.) Where in your body do you think this feeling isstrongest? (Jurists, 2005, modulating and expressing emotion)

Jodie Mentalized Affectivity 2The therapist leads Jodie to scan her body and then to focus on the muscles around her throat (Wallins, 2007, working with implicitly with feelings).Therapist: So your anger seems to be heaviest around your throat? Is that where your muscles are most tense?Jodie:Yes. (Her voice is raspy and parched)Therapist:I notice your voice is very strained at the moment. Im wondering if those muscles around your throat are trying to hold back your voice? I wonder what your voice would say if those muscles just let it out without holding back? (Jurists, 2005, modulating and expressing the affect)Jodie:It wouldnt be very nice? I dont think people would like it.Therapist:Maybe you might say something others dont want to hear? (mentalizing self and other constructions in the midst of aroused emotions)Jodie: Nothey definitely wouldnt want to hear it.Therapist:Whats it like to have to hold back what you are thinking and feeling because others wont like it or even worse, not like you? Jodie: It feels impossible. It feels like Ive got all this anger that I cant have. (Jodie is articulating the double bind her emotions give rise to in her self-other affect. As she does this she becomes calmer and sadder and less angry and jumpy. There is the beginnings of what Johnson, 1988, describes as accessing softer, primary emotions).

31Jodie Epilogue OneFits and Expectations

The Developmental Thread

Crystallization at 16Take Jodies fits. In therapy, Jodie and therapist explored antecedents, associated cognitions and the relational context of these events. What emerged was a pattern of Jodie feeling under pressure to compromise herself in the face of expectations of others. For example her father and his new wife demanded that she take in a boarder from their church to help pay for the mortgage while she lived in what was the family home. They came around to talk her into the arrangement. Rather than negotiate, Jodie barricaded herself in the shower while she had her fit. She reported going numb and splitting off from the voices outside her bathroom floor. Jodie had retreated into her powerless self-construct. In that moment she saw her father as someone too powerful to stand up to, and as someone who might withdraw her security and safety if she disappointed him. Like the proverbial deer in the spotlight, she was unable to fight or take flight and instead froze. Liotti (2004) is one of a number of contemporary theorists who discuss dissociative phenomena from an attachment perspective. Liotti proposes a developmental thread that runs from disorganised attachment in early development to a vulnerability to dissociation in later life. In keeping with the incomplete and incoherent narratives such clients have, Jodie could only hazily recall attachment experiences as a child. Her fits began in proper from the age of 16, at the time her mother left and her home. One of the key features of disorganised infants is that they are faced with the ultimate mixed message; that the person who is most available for secure attachment experiences is also the one that is most threatening in terms of either a possibly hostile response or an abject lack of responsiveness.

When Jodie was 16 these issues became real and stark with the crumbling of her family environment. When important others would place expectations she did not like, she felt torn between opposing imperatives of safety and security and asserting her identity and boundaries. These experiences became generalised to other relationships with people crucial to her safety and security. She told of a story with her boss who wanted her to continually work back without pay, and one day taking herself off to the toilet to have a fit when asked to do so. These fits took place in a relational field whereby Jodie was still dependant (remaining in the family home long after everyone else had moved on) on the same people who stood in the way of her development of identity (eg. her mother demanding she do chores because of the nebulous debt that Jodie supposedly owed her).

32Jodie Epilogue TwoThe Tradeoff

Saying No

The beginning of RAGE

Holding both mental states in mind (boyfriend)To explore these self-other constructs, Jodie was asked other-oriented questions and self-oriented questions. For example, Could you finish this sentence? When mum asked me to repay $50 it felt as if she regarded me as if I am.. What did her request say about you as a person? What would you have to believe about your needs in order to shut down like that in that situation? Jodie was often asked to sit in the unoccupied chair in the room. From there she imagined herself in a healthy adult or observer mode watching herself in the other chair in her usual compliant surrender mode. She imagined herself saying no to demands and telling herself that she could look after herself if she was rejected. She walked the room feeling the difference in her body position, her gait, and in the level of her shoulders between these two modes. After a while her fits began to change in quality. Where as she used to hide away or give in when faced with trading off her needs for security, she reported feeling overwhelmed by great rage that scared both her and others, unassuaged by their cajoling efforts. This rage seemed as out of her control and as out of the blue as her dissociative fits. These nascent expressions of Youngs (et al. 2011) angry child mode were employed in therapy as the building blocks for asserting boundaries and self-hood.33